Using spiritual interventions in practice: developing some guidelines from evidence-based practice.

Hodge, David R.

Spiritual interventions can be defined as "therapeutic strategies that incorporate a spiritual or religious dimension as a central component of the intervention" (Hodge, 2006a, p. 157). Many social work practitioners are interested in using spiritual interventions in practice (Sheridan, 2009). Yet, in spite of widespread interest, Sheridan's review of 15 studies found that respondent social workers frequently reported receiving minimal training on this general topic during their graduate education.

Lack of training on the proper use of spiritual interventions is a significant problem. Without appropriate guidelines to inform interactions with clients, unethical practices may result (Canda, Nakashima, & Furman, 2004). In some instances, harm may even be done to vulnerable clients as ethical and professional boundaries are breached (Hodge, 2004b).

The purpose of this article is to develop some guidelines for using spiritual interventions in practice settings.The aim is not to regulate the use of such interventions, but to enhance wellness. The NASW (1996) Code of Ethics affirms the importance of using interventions in an ethical, professional manner that fosters client well-being. Given the growing importance attributed to evidence-based practice (EBP) as a vehicle to help ensure this goal, these guidelines are drawn from this movement. Accordingly, the article begins by defining the concept of EBP.

DEFINING EVIDENCE-BASED PRACTICE

Originating in the field of medicine, evidence-based practice remains controversial in some social work circles (Adams, Matto, & LeCroy, 2009; Campbell, 2003; Morago, 2006). Despite this controversy, a growing number of scholars support the concept (Cnaan & Dichter, 2008; Drake, Jonson-Reid & Mayas, 2007; Gambrill, 2003; Kessler, Gira, & Poertner, 2005; Rubin, 2007). Further, the evidence-based movement is international in scope. Over the course of the past decade, the concept has gained popularity in Australia (Plath, 2006), the United States (Zlotnik, 2007), and the United Kingdom (Saks & Allsop, 2007), with various levels of government moving to incorporate evidence-based language into human service protocols.

Although a consensus may be emerging in support of EBP, there is no universal understanding of what the concept signifies (Chambless & Ollendick, 2001; Gambrill, 2006; Rubin & Parrish, 2007). Perhaps the most widely used definition in social work is based on Sackett, Straus, Richardson, Rosenberg, and Haynes's (2000) influential work in the field of medicine (Gilgun, 2006; McNeece & Thyer, 2004; Yunong & Fengzhi, 2009). Drawing on this work, McNeece and Thyer (2004) defined evidence-based practice as "the integration of the best research evidence with clinical expertise and client values" (p. 9). Similarly, the American Psychological Association (APA) Presidential Task Force on Evidence-based Practice (2006) defined it as "the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences" (p. 273).

A number of guidelines flow from these definitions that inform the use of spiritual interventions in practice settings. Although these guidelines are presented sequentially here, it may be helpful to bear in mind that they are more typically considered simultaneously in clinical settings. These guidelines can be summarized under the following four rubrics: (1) client preference, (2) evaluation of relevant research, (3) clinical expertise, and (4) cultural competency (Gilgun, 2006).

CLIENT PREFERENCE

Perhaps the most important guideline to consider regarding the use of spiritual interventions is client preference. The ethical principle of self-determination is featured prominently in the NASW (1996) Code of Ethics. Client autonomy is a central social work value that informs essentially all social work practice.

In addition to ethical principles, sound therapeutic reasons exist to respect client preference (Gilgun, 2006). Responding to clients' desires can enhance client buy-in regarding the therapeutic enterprise (Azhar & Varma, 2000). Increasing client engagement can foster better outcomes, a key concern of EBP.

Determination of client preference regarding the use of spiritual interventions is perhaps best viewed as an ongoing process. Initially, practitioners should determine clients' interest in spirituality and religion, the latter being the vehicle through which spirituality is commonly expressed (Gallup & Jones, 2000). This can be accomplished by conducting a brief spiritual assessment (Hodge, 2004a). Such an assessment consists of a few short questions, some of which are designed to gauge clients' interest in spirituality in the context of service provision (for example, "I was wondering if spirituality or religion is important to you") (Hodge, 2003).

It is important to assess clients' openness to spirituality, because many clients are uninterested in discussing spirituality in practice settings. Spirituality is a highly personal topic for many clients (Moss, 2005). Consequently, some individuals are hesitant to trust practitioners with this aspect of their being (Richards & Bergin, 2000), a stance that is understandable given the lack of relevant training many practitioners have received (Sheridan, 2009). Alternatively, some more secular individuals may find the discussion of spirituality irrelevant to their concerns. In short, practitioners have the responsibility to protect clients' rights to decline to use spiritual interventions, or to refrain from delving into spirituality, during counseling (Frame, 2003).

Not all clients, however, are closed or ambivalent to the idea of integrating spirituality into practice. Rather, research suggests that many people want to have their spirituality incorporated into the therapeutic dialogue. According to Gallup data reported by Bart (1998), 81 percent of the general public desires to have their spiritual beliefs and values integrated into the counseling process. Similarly, studies of clients have repeatedly found that many want to have their spirituality integrated into the therapeutic enterprise (Arnold, Avants, Margolin, & Marcotte, 2002; Dermatis, Guschwan, Galanter, & Bunt, 2004; Mathai & North, 2003; Rose,Westefeld, & Ansley, 2008; Solhkhah, Galanter, Dermatis, Daly, & Bunt, 2009).

Spiritual interventions represent an important method of incorporating clients' spiritual beliefs and values into therapy. Such interventions can tap both clients' desire to ameliorate their problems and their desire to grow spiritually (Hodge, 2008). Harnessing two "motivational engines" may produce better outcomes (Azhar & Varma, 2000; D'Souza & Rodrigo, 2004). For instance, if clients view an intervention as a form of spiritual practice, they may be more likely to continue to implement the intervention after the symptoms that sparked the initial consultation dissipate.

Assuming that clients are interested in the intersection between spirituality and practice, the use of possible interventions can be explored. Before any spiritual intervention is used, it should be fully explained and informed consent obtained (Miller, 2003). As postmodernism has illustrated, every spiritual intervention is a value-informed entity (Richards, Rector, & Tjeltveit, 1999). A neutral, or value-free, intervention does not exist. Each intervention reflects the values and beliefs of the spiritual framework in which it was developed (Slife & Whoolery, 2006).

Mindfulness meditation, for instance, was constructed within the parameters of a Buddhist worldview (Segal, Williams, & Teasdale, 2002). Accordingly, this intervention reflects certain implicit assumptions about the nature of reality, wellness, and how wellness is best achieved in this present dimension of existence. These assumptions may not be shared by those who hold different assumptions about reality and wellness. To help safeguard autonomy, the informed consent process should include a full description of the assumptions and values embedded in the intervention, along with an explanation of why it may be helpful (Richards & Bergin, 2005).

As mentioned, it is helpful to view informed consent as a process rather than a one-time event (Hodge, 2006b). Clients may change their minds, in either direction, at any point during counseling. For instance, clients may not have fully understood a procedure when it was initially described. Later in the process, they may decide they want to discontinue the intervention when they realize it conflicts with their values. Alternatively, clients may initially indicate they are uninterested in spiritual interventions, perhaps due to concerns that practitioners may not respect their spiritual beliefs and values. Later on, they may change their minds after interacting with, observing, and testing practitioners sufficiently to risk incorporating the spiritual dimension. Thus, clients' responses should be monitored on a continuous basis to ensure that self-determination is respected throughout the process, from engagement to termination.

Although client preference may be a particularly important guideline, other factors must also be considered. If clients are interested in using spiritual interventions to help ameliorate problems, these factors will come into play. Among these additional factors is an evaluation of the best available research on the interventions whose use is being contemplated.

EVALUATION OF RELEVANT RESEARCH

The second guideline is an evaluation of the research on those spiritual interventions that are relevant to the client's problem. It is widely acknowledged that practice decisions should be based on the empirical research (Cnaan & Dichter, 2008; Gambrill, 2003; Thyer, 2004). Clients should expect social workers to suggest interventions that have a high likelihood of ameliorating the presenting problem (Rosen, Proctor, & Staudt, 1999).

After conducting an individualized assessment, one option is to conduct a search for the best available research related to the challenges faced by the client (Kessler et al., 2005). What constitutes the "best available research" has been a subject of some controversy (Adams et al., 2009; Chambless & Ollendick, 2001; Morago, 2006; Plath, 2006). Epistemological assumptions about the nature of reality, and how that reality is known, influence understandings of what is and is not considered good evidence (Lincoln & Guba, 2003; Saks & Allsop, 2007).

Thyer (2008), consistent with APA Presidential Task Force on Evidence-based Practice (2006), defined the best available research broadly. As might be expected, randomized controlled trials and meta-analyses are included in this conceptualization. A wide range of alternative forms of evidence are also included, however, among them epidemiological studies, qualitative research, and case studies. In short, all available scientifically credible evidence that pertains to the issue at hand should be considered.

This expansive understanding of evidence is significant in that it includes forms of research that are more likely to be conducted in emerging areas, such as spirituality. Although unknown to some, a growing body of research on spirituality has accumulated over the course of the past few decades. In total, well over a thousand studies exist (Koenig, 2007).

Reviews of this research have become increasingly commonplace (Ano & Vasconcelles, 2005; Hackney & Sanders, 2003; B. R. Johnson, 2002; Koenig, McCullough, & Larson, 2001; Mahoney, Pargament, Tarakeshwar, & Swank, 2001; Musick, Traphagan, Koenig, & Larson, 2000; Pargament, 1997; Shreve-Niger & Edelstein, 2004). In aggregate, consistently positive associations have emerged between spirituality and a wide array of outcomes. In other words, higher levels of spirituality are typically related to better health and mental health.

Although most of the existing research has used cross-sectional designs, a growing number of studies have used experimental and quasi-experimental designs.These, and other types of prospective studies, have examined the effectiveness of various spiritual interventions with a variety of health and mental health outcomes. Although an extensive review of this literature is beyond the scope of the present article, it may be helpful to note the breadth of outcomes studied, a list that includes the following: addiction (Avants, Beitel, & Margolin, 2005), alcoholism (Walker, Tonigan, Miller, Comer, & Kahlich, 1997), anxiety (Azhar, Varma, & Dharap, 1994; Rajagopal, MacKenzie, Bailey, & Lavizzo-Mourey, 2002), bereavement (Azhar &Varma, 1995a), bipolar disorder (D'Souza, Rodrigo, Keks, Tonso, & Tabone, 2003), compulsive disorder (Gangdev, 1998), fear of falling (Zhang, Ishikawa-Takata, Yamazaki, Morita, & Ohta, 2006), neurosis (Xiao, Young,& Zhang, 1998), perfectionism (Richards, Owen, & Stein, 1993), schizophrenia (Wahass & Kent, 1997), and stress (Grossman, Niemann, Schmidt, & Walachc, 2004; Nohr, 2000).

An outcome that has received considerable attention is depression, one of the most common mental health problems (Koenig et al., 2001). These studies have typically used randomized controlled trials to examine the effectiveness of cognitive-behavioral therapy (CBT) modified with spiritual beliefs and practices drawn from clients' spiritual narratives. The effectiveness of spiritually modified CBT has been examined using values drawn from Islam (Azhar & Varma, 1995b), Christianity (Hawkins, Tan, & Turk, 1999; W. B. Johnson, Devries, Ridley, Pettorini, & Peterson, 1994; W. B. Johnson & Ridley, 1992; Pecheur & Edwards, 1984; Propst, 1980; Propst, Ostrom, Watkins, Dean, & Mashburn, 1992), and a generic spirituality (D'Souza, Rich, Diamond, Godfery, & Gleeson, 2002; D'Souza et al., 2003).

As was the case with the previously mentioned studies, the outcomes were generally positive, suggesting that the use of spiritually modified CBT may be warranted, particularly among Christians wrestling with depression (Baer, 2003; McCullough, 1999; Oman, Hedberg, & Thoresen, 2006). Different frameworks exist for classifying the effectiveness of interventions (for example, the Cochrane Collaboration, Common Elements, APA Division 12 [Society of Clinical Psychology]). On the basis of criteria developed by APA Division 12, spiritually modified CBT might be considered an empirically validated intervention for Christians struggling with depression (Hodge, 2006a). In other words, this approach appears to satisfy the stated criteria for either a well-established or probably efficacious treatment with this population (Task Force on Promotion and Dissemination of Psychological Procedures, 1995).

Practitioners interested in using spiritual interventions might familiarize themselves with this emerging body of research. Some commentators recommend evaluating research on the basis of a hierarchy of research methods. This hierarchy is typically ordered as follows (from more favorable to less favorable): systematic reviews or meta-analyses, randomized controlled trials, quasi-experiments, case-controlled or cohort studies, cross-sectional research, and case studies (Rubin & Parrish, 2007; Thyer, 2004).

Other observers have criticized this hierarchy, arguing that it privileges a particular epistemological worldview, sometimes referred to as "modernistic positivism" (Adams et al., 2009; Gilgun, 2006; Morago, 2006; Plath, 2006; Slife & Gantt, 1999).

Practitioners who hold what might be called a "postmodern interpretivistic" worldview may wish to evaluate evidence using a different matrix. It is notable that the Cochrane Collaboration has established a "methods group" to include evidence from qualitative studies into its systematic reviews (Pearson, 2007).

Regardless of the worldview used to assess evidence, the aim is to develop a working understanding of the state of the research as it intersects a given outcome with a particular population. Practitioners should not assume that a particular intervention that is effective with Muslims, for example, will be effective with Hindus, even though clients from both traditions may be wrestling with the same issue. Different spiritual understandings tend to result in culturally distinct worldviews (Richards & Bergin, 2000). In the same way that interventions developed, tested, and validated with one cultural group may not prove effective with another, so to, interventions that are effective with one spiritual population may not be effective with another because of differences in how the populations construct reality (Chambless & Ollendick, 2001). Although evidence obtained using a particular intervention with one group can be considered suggestive in terms of its utility with other groups, it should not be considered determinative.

An assessment of the best available research is not conducted in isolation. Other factors must be considered in tandem with the research on spiritual interventions. Among these additional considerations is clinical expertise.

CLINICAL EXPERTISE

A central issue in the selection of spiritual interventions is clinical expertise (Drake et al., 2007).The NASW (1996) Code of Ethics requires practitioners to provide services only within the boundaries of their areas of competence (1.04a). A number of implications flow from this principle.

When considering various interventions, practitioners should consider their degree of training and experience using each intervention (Canda & Furman, 2010). Spiritual interventions should only be used when sufficient training has been received to ensure that the intervention can be implemented in a professional manner (Richards & Bergin, 2005). In the same way that social workers trained solely in brief therapy might avoid using psychodynamic interventions, practitioners should typically refrain from using spiritual interventions with which they have minimal familiarity. This is a particularly significant issue in light of the lack of training in spiritual interventions many practitioners have received during their education (Sheridan, 2009). Clients have a right to expect that mental health professionals have some degree of expertise in the interventions they implement.

Fortunately, an increasing number of options are available to assist practitioners in acquiring the necessary training. As suggested in the previous section, a growing body of literature exists on spiritual interventions (Derezotes, 2006; Hodge, 2008; Smith, Bartz, & Richards, 2007; Stoltzfus, 2007). An increasing number of social work programs offer elective courses on spirituality (Canda, 2005). Training opportunities may also be available at the annual conferences of professional organizations, particularly those specializing in spirituality.

When discussing spirituality with clients, it is important to focus on solving clients' problems (Hodge, 2005). A substantial degree of overlap exists between therapy and spiritual direction, a practice designed to increase a person's intimacy with God or the Transcendent (Ganje-Fling & McCarthy, 1991). Practitioners, perhaps particularly those interested in spirituality, can inadvertently fall into the role of a spiritual director when exploring the issue of spirituality. For most practitioners, however, this vocation lies beyond the purview of their professional experience.

Clergy, however, have expertise in the area of spirituality. Accordingly, practitioners may wish to collaborate with clergy members in areas that fall outside the parameters of their professional competence (Gilbert, 2000). For instance, consultation might be helpful in the process of constructing spiritual interventions that resonate with clients' spiritual traditions.

For instance, as implied earlier, a number of well-designed studies suggest that CBT modified with beliefs and practices drawn from clients' spiritual traditions may be an effective spiritual intervention for problems such as depression (Hodge, 2006a; McCullough, 1999). In addition, many practitioners are familiar with the basic precepts of CBT, which is likely to heighten the utility of this spiritual intervention. Practitioners may not, however, be familiar with the norms within clients' various spiritual traditions. In such cases, collaboration with clergy can aid in helping to craft spiritually modified CBT interventions that more accurately reflect clients' value systems.

The prospect of differences in worldviews between practitioners and clients implicitly raises the issue of working across cultures. Although related to clinical expertise, the subject of cultural competency is perhaps best seen as a separate principle to be considered when selecting spiritual interventions.

CULTURAL COMPETENCY

Cultural competency is required to select and implement spiritual interventions within the context of clients' cultures. As implied earlier, the expression of spirituality with other individuals who hold similar experiences of the Transcendent leads to the establishment of religious communities with distinct cultures, which are sometimes referred to as "spiritual traditions" or "faith traditions" (Richards & Bergin, 2000; Van Hook, Hugen, & Aguilar, 2001). Reflecting this reality, NASW's (2001) Standards for Cultural Competence in Social Work Practice suggest that social workers should exhibit cultural competency in their work with people from these traditions. Spiritual competence can be understood as the dimension of cultural competence that focuses on developing competence with people from various spiritually animated cultures (Hodge & Bushfield, 2006).

In a manner analogous to cultural competence, spiritual competence can be understood as a process whereby practitioners develop expertise in three interrelated areas: (1) a growing awareness of their own value-informed spiritual worldview and its assumptions, limitations, and biases; (2) an empathic understanding of the client's spiritual worldview; and (3) an ability to design and implement interventions that resonate with their client's spiritual worldview (Hodge & Bushfield, 2006). Thus, spiritual competence is not a static entity but a dynamic set of attitudes, knowledge, and skills related to various spiritual traditions that can be developed over time (Sue & Sue, 2008). As such, spiritual competence is perhaps best understood as a continuous construct.

Developing an awareness of one's own worldview plays an important role in managing what might be called "spiritual countertransference" (Frame, 2003; Genia, 2000; Hodge, 2002a; Miller, 2003).When working with individuals from a different spiritual worldview, practitioners' unresolved personal issues may unconsciously affect their interactions with clients. For instance, practitioners who have rejected the faith tradition of their family of origin may consciously or unconsciously react when encountering clients who hold that particular worldview. Verbal and nonverbal expressions of disapproval can damage and even end the therapeutic relationship. To manage these types of reactions, self-exploration can be a particularly useful tool, especially when conducted in a supervisory context (Frame, 2003).

Developing an awareness of the strengths and limitations of one's own worldview helps in the process of developing an empathic understanding of culturally different spiritual worldviews. Practitioners do not have to agree with the worldviews affirmed by their clients (NASW, 2001) .They should, however, develop an empathic understanding of these alternative constructions of reality. Understanding the limitations of one's own worldview can aid in this process (Sue & Sue, 2008).

Working toward an appreciation of the internal logic of various spiritual belief systems is critical because of the differences in various spiritual cultures. Spirituality can affect beliefs and practices in a wide range of areas such as child care, communication norms, death and burial rituals, diet, family relations, financial practices, gender interactions, marital relations, medical care, recreation, schooling, and work habits (Richards & Bergin, 2000; Van Hook et al., 2001). In some cases, the differences between worldviews can be extreme. As acknowledged in the DSM-IV-TR (American Psychiatric Association, 2000), what is viewed as an indicator of pathology in the dominant secular culture can be viewed as a strength within some minority spiritual cultures.

As a result, interventions that are congruent with one culture may be incongruent in another (Richards & Bergin, 2002). For instance, within the context of many tribal worldviews, a spiritual intervention to restore balance might be an appropriate choice to address a mental health problem with a Native American client (Weaver, 2005). Yet such an intervention may be seen as an irrational waste of time to practitioners operating from within the parameters of the dominant secular culture (Cross, 2001 ; Gray, 2008).

The application of incongruent interventions can even exacerbate problematic functioning (Gotterer, 2001; Reddy & Hanna, 1998). To follow up on the aforementioned example, the use of interventions that are inconsistent with Native culture may increase negative affect by creating further imbalance within the context of the client's worldview (Cross, 2001). By using interventions that represent foreign intrusions into clients' understandings of reality, practitioners risk harming the therapeutic relationship, their standing in clients' communities, and clients' themselves.

To select interventions that are congruent with clients' worldviews, it is necessary to have some understanding of the beliefs and values within those worldviews (Gambrill, 2006; Gilgun, 2006). While working to cultivate an understanding of various traditions, it is useful to remember the diversity that exists within each individual tradition (Hodge, 2002b). Individuals who self-identify as members of a given spiritual tradition can affirm a wide variety of beliefs, including beliefs that are at odds with the norms of the tradition. As a result, it is helpful to view traditions as malleable, flexible templates that suggest, rather than require, the presence of particular beliefs and practices.

A number of steps can be taken to increase one's knowledge and appreciation of various spiritual narratives (Richards & Bergin, 2(i)05). For example, one might read content on frequently encountered spiritual traditions, preferably content written by cultural insiders or sympathizers (Ginsberg, 1999). Visits to local houses of worship can also be helpful in enhancing knowledge. Congregants are often willing to answer questions about their spiritual tradition, and such visits can lead to the establishment of linkages with clergy members. Relationships with other practitioners who are more conversant in the norms of a particular tradition can also be a helpful source of information.

In some cases, it may be necessary to arrange a referral to a practitioner who is more spiritually competent (Reamer, 2006). For instance, some practitioners may not have the necessary skills and knowledge to work with clients from a particular tradition in a competent manner. Others may feel that practitioner-client value differences preclude an effective working relationship. Another group of practitioners may feel the value differences are surmountable but that they have not fully worked through spiritual countertransference issues. In these and other situations, referrals should be explored if clients are at risk of being subjected to culturally insensitive practice. The essential point is to prioritize clients' welfare.

LIMITATIONS AND QUALIFICATIONS

Although a full discussion of the limitations and qualifications of the approach outlined here is beyond this article's scope, it may be helpful to highlight a few pertinent issues. Spirituality is but one characteristic of diversity. It is important to note that other characteristics of diversity also exist and can shape interactions. When considering the use of spiritual interventions, all diversity characteristics must be taken into account.

For instance, African Americans tend to be very devout, and spirituality is often used by members of this population to cope with challenges (Hodge, & Williams, 2002). The high level of salience attributed to spirituality might suggest that African Americans would often be interested in spiritual interventions. However, because of widespread cultural mistrust of mental health providers, who are often secular and white, African Americans may not be open to spiritual interventions (Lyles, 1992; Whaley, 2001).

It should also be emphasized that spiritual interventions may be contraindicated in some situations (Frame, 2003; Richards & Bergin, 2005). As implied earlier, spiritual interventions are clearly contraindicated when clients are uninterested in spiritual interventions, insufficient research on the intersection of spirituality and a given problem area exists, or practitioners lack clinical expertise with a given intervention or have insufficient cultural competency with the client's spiritual tradition. Likewise, the incorporation of spirituality into therapy when there is no connection to the presenting problem should also be avoided. Spiritual interventions are also contraindicated when working with minors, unless the practitioner has obtained permission from a client's parents or legal guardians.

CONCLUSION

Spirituality is increasingly recognized as a significant client strength that is often instrumental to well-being. In recognition of this perspective, the Joint Commission--perhaps the foremost health care accrediting body in the United States--now requires a spiritual assessment in hospitals and many other behavioral health settings (Hodge, 2006b; Koenig, 2007). This assessment lays the foundation for the subsequent use of spiritual interventions that can help clients cope with, or ameliorate, problems.

Although many practitioners are interested in using spiritual interventions in clinical settings, the literature indicates that they have frequently received little training on this topic during their graduate educations. Accordingly, this article has discussed four guidelines from the EBP movement to assist practitioners in using spiritual interventions in an ethical, professional manner that fosters client well-being: client preference, evaluation of relevant research, clinical expertise, and cultural competency (which should be understood as including spiritual competency).

Thus, EBP in the area of spirituality might be conceptualized as the integration of the best available research on spirituality with clinical expertise in the context of client preferences, characteristics, and spiritual cultures. As this definition implies, the process is more fluid than sequential and should always involve clients in the decision-making process. Thus, developing familiarity with the relevant research on spirituality enables practitioners to incorporate their assessment of the best available evidence into the informed consent process. Similarly, practitioners can advise clients of their level of expertise with various interventions and their degree of spiritual competency. Various options can be explored in a collaborative manner that prioritizes a client's desires and takes into account other characteristics of diversity. Through this process, various options will be eliminated until an optimal intervention is mutually agreed on.

The NASW (1996) Code of Ethics requires social workers to use interventions only after engaging in the necessary study and training to ensure both the competency of their work and that harm is not done to clients (1.04). Similar comments are made about the use of interventions in newly emerging areas, a category that would include the use of spiritual interventions. This article fills a gap in many social workers' graduate education by drawing on the EBP movement to help practitioners use spiritual interventions in an ethical, professional manner that fosters client well-being.

Original manuscript received May 20, 2008

Final revision received October 22, 2009

Accepted October 26, 2009

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David R. Hodge, PhD, is assistant professor, School of-Social Work, Arizona State University and senior nonresident fellow, Program for Research on Religion and Urban Civil Society, University of Pennsylvania, Philadelphia. Address correspondence to the author at Mail Code 3920, CoPP, 411 North Central Avenue, Suite 800, Phoenix, AZ 85004-0689.