Spiritual assessment and native Americans: establishing the social validity of a complementary set of assessment tools.
Hodge, David R. ; Limb, Gordon E.
Due to recent changes in the Joint Commission's accreditation
standards, spiritual assessments are now required in behavioral health
organizations providing addiction services, hospitals, and many other
health care settings (Hodge, 2006; Koenig, 2007). To some extent, the
Joint Commission's new assessment requirements represent a
double-edged sword for Native American clients.
From a positive perspective, spirituality is a central component of
most Native American cultures (Frame, 2003; Fuller-Thomson &
Minkler, 2005; Graham, 2002; Weaver, 2005). Furthermore, spirituality is
commonly viewed as essential to the promotion of health and wellness
(Coates, Gray, & Hetherington, 2006; Gilgun, 2002; Lowery, 1999;
Weaver, 2002). Put differently, spirituality is typically viewed as a
critical strength that must be operationalized to address the challenges
encountered by Native people (Cross, 1997; Limb & Hodge, 2008;
Stone, Whitbeck, Chen, &Johnson, 2005).Accordingly, to work
effectively with Native clients, it is necessary to conduct a spiritual
assessment to understand the relationship between spirituality and
wellness from their perspective (Cross, 2001; Gesino, 2001 ; Gone,
2004).
Conversely, a point of concern is the validity of the instruments
used to conduct the assessments (Weaver, 2005). The suppositions of
mainstream discourse tend to inform the assessment process (Gilligan,
1993; Sue & Sue, 2008; Yellow Bird, 2004). Within the dominant,
secular culture, spirituality is often compartmentalized from other
dimensions of existence, accorded a secondary status, and even viewed as
an indicator of dysfunction (Armstrong, 2000; Cross, 2001; Ellis, 1980).
In contrast to the dominant culture, Native Americans commonly view
spirituality as a strength, accord it a primary role, and believe that
it informs all other dimensions of existence (Cross, 2001; Napoli, 1999;
Pace et al., 2006). As recognized in the Diagnostic and Statistical
Manual of Mental Disorders (American Psychiatric Association, 2000),
differences in value systems can lead to misdiagnoses and even harm to
clients. In extreme cases, cultural strengths can be understood as
indicators of pathology (American Psychiatric Association, 2000).
Particularly concerning is that Native American spirituality may fall
into this category (Cross, 2001).
Consequently, it is imperative that culturally valid assessment
approaches be used with Native people (Zvolensky, McNeil, Porter, &
Stewart, 2001). To avoid implicitly imposing a culturally foreign value
system, assessment tools must be modified for use with Native Americans
(Weaver, 2005).Yet surprisingly little validation research has been
conducted from a Native perspective (Cross, 2001; Green, 1999; Weaver,
2005).
SOCIAL VALIDITY: ONE APPROACH TO ESTABLISHING VALIDITY
Various methods exist for establishing validity (Babbie, 2007;
Denzin & Lincoln, 2003; Jordan & Hoefer, 2001). As already
implied, the suppositions that inform mainstream discourse in the mental
health professions often differ substantially from those held by Native
tribes (Coates et al., 2006; Gone, 2004). Consequently, traditional
approaches to validation may be ineffective with Native Americans
because they are largely based on the same suppositions that inform
discourse in the dominant culture (Pace et al., 2006).To address this
problem, Pace and associates recommended qualitative validation research
in which Native Americans conversant in Native culture provide feedback
on items from a Native perspective.
This recommendation is highly congruent with the concept of social
validity (Foster & Mash, 1999; Wolf, 1978). This concept emerged in
the field of applied behavioral analysis amid concerns over the
unsuccessful implementation of interventions due to perceptions among
target populations that the interventions lacked relevance to their
needs and aspirations. The absence of successful outcomes fostered the
development of a number of prescriptions, including the need to show
that interventions will be accepted and used if implemented among a
particular social group and the need to document the social importance
of treatment goals and outcomes.
Similar in nature to the notion of cultural validity (Solano-Flores
& Nelson-Barber, 2001), social validity can be understood as the
degree to which members of a particular culture believe that a given
intervention is valid, relevant, and consistent with their cultural
values and aspirations. The higher the degree of perceived congruence
with the social group's values and goals, the greater the level of
social validity and, consequently, the greater the probability that a
given intervention will be successfully implemented by members of the
group (Gresham & Lopez, 1996; Lane & Frankenberger, 2004).This
general understanding of social validity was used to establish the
validity of the set of assessment instruments discussed in the following
section.
A COMPLEMENTARY SET OF SPIRITUAL ASSESSMENT INSTRUMENTS
Qualitative assessments are required to fulfill the Joint
Commission's assessment standards (Hodge, 2006). Although many
spiritual assessment instruments exist, most of these use quantitative
approaches. The Fetzer Institute (1999) and Hill and Hood (1999) have
compiled a number of widely used quantitative measures. Some new
qualitative assessment tools have been developed in response to the
Joint Commission's standards (Koenig, 2007). Among these is a
complementary set of six instruments (Hodge, 2005b). This family of
qualitative instruments is unique in the sense that it is the only set
of which we are aware that is designed to highlight different aspects of
clients' spirituality. The set consists of one brief instrument and
five comprehensive instruments.
As stipulated by the Joint Commission, the brief instrument is
administered initially (Hodge, 2004). This short, preliminary assessment
is designed to determine the effect of clients' spirituality on
service provision and whether an additional, comprehensive spiritual
assessment is warranted (Hodge, 2006). If an in-depth assessment is
called for, the various comprehensive instruments provide practitioners
with options (Hodge, 2005b).Because both clients and practitioners have
a variety of needs and interests in any given clinical context, some
assessment approaches may work better in certain situations, whereas
other instruments may be a more appropriate choice in other settings
(Hodge, 2005a).
The five comprehensive instruments consist of one completely verbal
approach--spiritual histories (Hodge, 2001a)--and four pen-and-paper,
diagrammatic approaches--spiritual lifemaps (Hodge, 2005d), spiritual
genograms (Hodge, 2001b), spiritual eco-maps (Hodge & Williams,
2002), and spiritual ecograms (Hodge, 2005c). Spiritual histories
explore clients' personal spiritual journeys over the course of a
generation. In a manner analogous to conducting a family history,
practitioners verbally examine clients' spiritual stories from
childhood through to the present. Spiritual lifemaps represent a
diagrammatic alternative to verbally based spiritual histories.
Spiritual lifemaps chart, or map, clients' spiritual life stories
in a pictorial format. As is the case with other diagrammatic
approaches, pens, markers, and other drawing instruments are typically
used to visually depict spiritual information on a large sheet of paper.
Although spiritual histories and lifemaps focus on one generation
(that is, one person's story from childhood to the present),
spiritual genograms illustrate the flow of spirituality across at least
three generations. In a manner analogous to traditional genograms,
spiritual genograms provide tangible, graphic representation of
spirituality across at least three generations through a family tree
that has been modified to highlight spiritual information and
intergenerational interactions and assets. Spiritual eco-maps focus on
clients' current spiritual relationships. In contrast with the
aforementioned assessment instruments--which all focus on some portions
of clients' spiritual stories as they exist through time--spiritual
eco-maps highlight clients' present relationships to current
spiritual systems in their environments. Spiritual ecograms combine the
strengths of spiritual eco-maps and genograms in a single instrument. As
such, they depict both present relationships to present environmental
systems and the flow of spirituality across three generations in a
single diagrammatic instrument. Readers interested in further
information on these six instruments are encouraged to obtain the
articles cited earlier or the following review articles (Hodge, 2005a,
2005b).
Given the potential impact of the Joint Commission's standards
on Native Americans, the present study examined the social validity of
this complementary set of assessment instruments. Toward this end, the
study sought to answer the following interrelated questions: How
consistent is the set of six assessment instruments with Native culture?
What are the set's strengths and limitations in terms of working
with Native Americans? And how could the set be changed to be more
valid, relevant, and consistent with Native American culture? In keeping
with Pace et al.'s (2006) recommendations, individuals highly
conversant in Native culture were solicited to answer these questions.
METHOD
Participants
Consistent with previous research, a hybrid purposive/snowball
sampling strategy was used to identify experts in Native American
culture (Weaver, 1999). One of the authors is a Native American scholar
with extensive research and practice experience with Native populations.
He contacted a number of potential participants who are widely
recognized to have extensive knowledge of Native American culture. The
purpose of the present study was explained to these individuals, and
they were asked to identify other experts.
Sixty-seven Native American experts were identified using this
sampling strategy. Of these, 50 agreed to participate in the study,
resulting in a sample size consistent with previous, related research
(Weaver, 1999, 2000). A 75 percent response rate is typically considered
to be more than acceptable (Babble, 2007).
The study participants exhibited a relatively wide range of tribal,
geographic, and spiritual affiliations, which enhances the validity of
the study by incorporating diverse perspectives (see Table 1). For
instance, the geographic diversity helps to mitigate any regional bias
that may exist. The average age of participants was approximately 50
years; close to two-thirds of the sample was female. Ninety percent had
a social work degree, and the average length of professional experience
was approximately 17 years.
Survey Instrument
In addition to demographic items, the mixed-method survey included
a brief review of the Joint Commission's assessment standards, an
orientation to the set of instruments, general conceptual overviews of
the six assessment instruments, and representative examples of each
diagrammatic instrument. The overviews consisted of approximately three
paragraphs and, in tandem with the pictorial examples, provided an
understanding of each assessment instrument at the conceptual level.
Each conceptual overview was followed by a quantitative question
designed to assess the instrument's level of consistency with
Native American culture. These items were constructed using the
phrase-completion methodology, an approach that may increase the
validity and reliability of quantitative data (Hodge & Gillespie,
2007; Visser, Krosnick, & Lavrakas, 2000). Respondents were
presented with each instrument and were asked to assess the degree of
cultural consistency on a scale ranging from 0 = absence of consistency
with Native American culture to 10 = complete consistency with Native
American culture.
To clarify what was meant by the term Native American culture, it
was noted that many differences exist among Native American tribes.
Concurrently, respondents were informed that a number of values are also
widely shared among Native Americans, which serve to demark them as a
group. Accordingly, respondents were informed that Native American
culture signifies "this general, common culture that serve[s] to
distinguish Native Americans as a distinct population."
The presentation of the six assessment instruments was followed by
four questions about the overall set. The first question asked
respondents to assess the degree of cultural consistency of the overall
set of six instruments ("Generally speaking, this overall set of
six instruments is: --") using the same 0 to 10 scale described
earlier. The remaining three questions were open-ended, qualitative
items designed to assess the set's strengths, limitations, and
areas for improvement.
The first item asked, "In terms of working with Native
Americans, what are the strengths of the overall set?" The second
item was identical, apart from using the term "limitations"
instead of "strengths." The final question asked, "How
could this set of six instruments be improved to be more valid,
relevant, and consistent with Native American culture?"
The survey was pilot tested with a convenience sample of five
individuals attending the American Indian/Alaska Native Social Work
Educators Association Meeting. Prior to this meeting, we removed obvious
inconsistencies with Native culture. The meeting attendees were
presented with this revised instrument and asked to assess the
survey's content and design for clarity and face validity. The
resulting suggestions, which were minor in nature, were incorporated
into the final survey, which was then distributed to potential
respondents.
Procedures
To minimize the burden on potential respondents, individuals were
given the option of completing the survey online or on paper. All
participants chose the online option. Research suggests that response
rates, and the resulting data, are relatively comparable for Web-based
and paper surveys (Denscombe, 2006; Kaplowitz, Hadlock, & Levine,
2004). All communication occurred in English. Respondents received a $50
honorarium in appreciation for their time.
Data Analysis
For the quantitative data, means, standard deviations, ranges, and
modes were computed and reported. For the qualitative data, an
inductively oriented constant comparative methodology was used to
analyze the data (Padgett, 2008). Open coding was conducted, allowing
the data to drive the construction of themes. Using this approach, data
were examined across cases for similarities, patterns, and common
concepts. In a recursive process, these commonalities were continually
compared with similar phenomena across cases to identify, classify, and
refine the emerging themes (Dye, Schatz, Rosenberg, & Coleman,
2000).
Primary and secondary themes were identified, organized, and
labeled. Representative paraphrases or quotes are used to illustrate
these themes. The results of the analysis are presented in four
subsections corresponding to the study's research questions:
Cultural Consistency, Strengths of the Instruments, Limitations of the
Instruments, and Areas for Improvement.
RESULTS
Cultural Consistency
As Table 2 shows, spiritual histories were ranked highest in terms
of level of cultural consistency with Native culture. Spiritual lifemaps
and eco-maps also fared comparatively well. Conversely, spiritual
genograms were ranked lower. Brief assessments and spiritual ecograms
also received comparatively low scores.
The overall set received a score of just over 6 on the 0 to 10
scale. It should also be noted that all the instruments fell on the
consistency end of the 0 to 10 scale. Thus, although differences in the
cultural consistency emerged between the various instruments, these
variations occurred on the consistency side of the scale. The following
qualitative items help to illuminate these findings.
Strengths of the Instruments
Qualitative analysis revealed two primary strengths. The first was
the set's ability to explore a foundational dimension of Native
American culture. Within the context of this primary theme, two
subthemes emerged that can be summarized as (1) relief that mental
health professionals were finally addressing spirituality and (2)
clinical implications of exploring an area of significance to many
clients. The second primary theme was the set's flexibility.
Ability to Explore a Foundational Cultural Dimension. Regarding the
first theme, a number of respondents stated that the assessment
instruments provide a method to explore an essential facet of Native
American culture. As one respondent noted, "Spirituality is an
important component of many Native people's lives. This overall set
makes great strides in that recognition and assessment. "Another
stated, "It is important to capture the spiritual dimension in some
way."
Within this broader theme, a subtheme emerged expressing relief
that mental health professionals were finally developing tools to
explore this critical area. As one expert stated, "It is finally
addressing an area that, for Native Americans, needs to be addressed for
balance and harmony." After noting that the set represents a good
beginning, another respondent stated, "At least someone is starting
to ask these questions. I think that will be the response of many
Natives--at least someone cares [enough] to even ask the
questions."
Another subtheme emphasized the clinical implications of exploring
an area of significance to many clients. For instance, one individual
commented that the instruments "provide ways to 'get at'
[a client's] spirituality in a very thorough way."
Consequently, their use can enhance the therapeutic relationship between
the worker and the client while fostering a more collaborative
relationship. One person described them as a "terrific effort to
get at significant information that intersects health, well-being and
treatment expectations--and implementation can enhance relationships
[between] worker/client and promote a more collaborative stance."
Flexibility of the Set. As noted, the other major strength that
emerged was flexibility. The flexibility was operationalized in a number
of ways. For example, it was noted that the set provides different
assessment options, including both brief and comprehensive instruments,
completely oral as well as diagrammatic approaches, and outlets for
artistic expression. On a slightly different note, others noted that the
set was sensitive to differences in client spirituality while exploring
individual, family, and community or tribal dimensions of spirituality.
Commenting on this characteristic of the set, one respondent stated,
"It is very comprehensive and allows for both range and depth of
information to be gathered. It addresses the major aspects of
spirituality--I can't think of any other broader categories to
include."
Other manifestations of the set's flexibility were that it
accommodates diverse expressions of spirituality, allows clients to
individualize their responses, can be used with individuals with
differing levels of acculturation to mainstream culture, and can be
applied in most tribal settings and contexts. Perhaps the concept of
flexibility was best summarized by the following comment: "These
six instruments complement one another and provide a clear methodology
to assess the various ways spirituality affects [Native clients']
lives." These perceived strengths, however, must also be considered
in light of some limitations.
Limitations of the Instruments
Analysis revealed five prominent limitations: (1) the complexity of
the some of the instruments, (2) the need to administer the assessment
using language that reflects common Native phraseology, (3) the private
nature of many Native American spiritual practices, (4) the capability
of practitioners to administer the assessments, and (5) incompatibility
with Native American worldviews.
Complexity of Some Instruments. Some of the instruments were deemed
difficult to understand and operationalize. In this area, the two
instruments that received the lowest quantitative scores--spiritual
genograms and eco-maps--were cited (for example, "[spiritual]
genograms are too confusing"). The following comment reiterated
this point while providing some context regarding the high score
accorded to spiritual histories: "Some of the instruments seem a
bit complicated, time-consuming, and in written form, whereas Native
Americans may respond better to more oral/narrative approaches."
Importance of Native Terminology. The language used to
operationalize the instruments was also cited as a limitation. As one
respondent observed, the items were "often full of research lingo,
which may not always translate well in the community." The use of
common Native terminology was deemed critical (for example, using
"Creator" rather than "God"). This practice helps
legitimize traditional expressions of spirituality. As one individual
noted, "As there are a vast number of tribes, and therefore tribal
beliefs, I believe that the more inclusive the language, the better the
response. The assessment process should be customized to reflect the
individual/tribal worldview of each client."
Private Nature of Spiritual Practices. The private nature of many
Native American spiritual practices was another theme that emerged.
Respondents pointed out that many spiritual beliefs and practices are
private or secret and cannot be discussed with outsiders (for example,
talking about the dead). As one person stated, "Some ceremonies are
considered sacred and only shared with someone of the same culture
(tribal belief)." Because a spiritual assessment may touch on such
beliefs, it is critical that practitioners create space for clients to
opt out of this part of the assessment process. This point is captured
in the following comment: "Questions regarding secret or private
information, especially on ceremonies, rituals and practices, must be
optional--the client must be allowed to be comfortable in omitting
certain questions without perceiving being labeled [or
disparaged]."
Capability of Practitioners. The above themes are all implicitly
related to the next theme--the capability of practitioners to administer
the assessments appropriately. Specific concerns mentioned included the
ability of practitioners to develop knowledge of culturally different
worldviews, refrain from imposing their values, respect different value
systems, and engender sufficient trust that Native clients will feel
safe sharing pertinent information. These intertwined issues are
illustrated in the following comment:
The usefulness [of the instruments] truly
depends upon context. Who is asking these
questions, within what tribal culture, for what
purpose? Native spirituality has been feared,
misunderstood, misconstrued, and exploited
for centuries by government officials, researchers,
and the general non-Native public. Even if
tribal participants are able to describe their beliefs
and practices in response to non-directive, nonbiased
questions, understanding depends upon
the person conducting the assessment. Does the
interviewer share [their] cultural and experiential
worldview? If not, can they "shift center" to
understand the emic view in a way that is helpful
to the teller? And perhaps most importantly,
will this experience result in greater self-esteem
and self-determination for participants, a focus
on internal and environmental strengths, and
vision for the future?
Echoing these concerns, another respondent noted that "the
validity and reliability of responses may ultimately be determined by
the [skills and abilities of the] interviewer."
Incompatibility with Native Worldviews. The final theme that
emerged was incompatibility with Native worldviews, which may help to
explain some of the low scores on the cultural consistency measure. Some
respondents felt that the instruments reflected precepts drawn from the
dominant culture. One person felt that "mainstream concepts of
religion and spirituality seem to be the underlying constructs on which
the questions are based." In a similar manner, another person
stated, "Overall, they are based upon majority society concepts and
worldviews," a response that suggests that areas for improvement
exist.
Areas for Improvement
Analysis produced four themes in response to the question asking
how the six instruments might be changed to be more valid, relevant, and
consistent with Native American culture. Echoing many of the
observations regarding limitations, these four themes can be summarized
as follows: (1) use of appropriate language, (2) practitioner training,
(3) validation with individual tribal cultures, and (4) presently
acceptable (that is, no changes needed).
Appropriate Language. Many respondents stressed the importance of
using appropriate language in the course of using the instruments with
Native clients. As one person put it, the "terminology can be
changed to open up the range of appropriate responses to particular
questions." Specific suggestions included using vocabulary that
matches the worldview of the client once that worldview is known;
phrasing questions in a neutral, unbiased manner; using straightforward
vocabulary that is readily understood by clients; constructing indirect
questions; using short, open-ended questions; and legitimating
traditional expressions of spirituality by using common Native
terminology. This last point is illustrated by a respondent who observed
that "language such as 'Creator' [and]
'Ceremonies' has been used very well in the context of these
instruments so I would encourage the use of and incorporation of more
cultural terms such as Tribe, Clan, Spiritual advisor, Elders, teachings
of the ancestors, [and so forth] to enhance this very important
work."
Practitioner Training. Closely related to the issue of appropriate
language was the next theme, practitioner training. In addition to using
language appropriately, respondents mentioned the importance of creating
the right atmosphere for conducting an assessment, developing knowledge
about specific tribal cultures, and allowing sufficient time to conduct
the assessment. Many of the above issues are illustrated by the
following comment:
Focus on simplicity, narrative, letting people tell
their stories, being careful to respect the local
culture(s), and not appearing to be too curious
and inquisitive since so many white people
have simply been too curious. Whites have
come in and done endless field studies, written
books and misused Native American wisdom,
so people are cautious about what they share.
.... It isn't respectful to ask a lot of questions.
The opportunity to tell our story is a very nice
part of this [set of instruments]. We use stories
and telling our stories can help us frame our
narratives, make sense of our experiences and
lives, grieve, and cope with trauma.
Given the historical exploitation and abuse of Native spirituality,
another expert recommended that practitioners consider how any
information that is shared might be safeguarded. Another emphasized the
importance of informed consent, so that clients understand what will
happen with the information they share and the consequences of their
participation.
Another issue mentioned was the interwoven nature of religion with
culture. Although spirituality is often compartmentalized among members
of the dominant culture, among many Native cultures the separation of
spiritual and material spheres is absent, as one respondent observed:
"Some Native peoples do not see themselves as separate from their
spirituality, [their] connectiveness to the Creator. My belief system is
me as I exist. Religion is our way of life, not a separate entity of
myself." The comments related to the theme of practitioner training
are perhaps best summed up by the following quote: "Provide solid
training for all [practitioners]."
Validation with Individual Tribal Cultures. Some respondents
recommended validating the instruments with specific tribal cultures as
a way to improve their validity and relevance. It was noted that
cultures vary from tribe to tribe. Validating the instruments with a
given tribe would help improve their relevance to members of that tribe.
As one respondent recommended," Pilot with diverse tribal
communities and urban Indian communities, across class, gender, age,
acculturation level and spiritual/ religious backgrounds. Tribal
communities are extremely complex systems and it will be very hard to
generalize findings to what is referred to as Native American
culture." Similarly, another highlighted the importance of
"empower[ing] tribal communities to modify [the] instruments as
needed."
Presently Acceptable. Finally, some individuals indicated that the
instruments were acceptable in their present state. For example, one
respondent stated, "This instrument [or set] is fine."
Likewise, another commented, "This instrument is relevant to Native
American culture as a whole." This sentiment is in keeping with the
high scores recorded on the cultural consistency scale.
DISCUSSION
This mixed-method study sought to establish the social validity of
a complementary set of spiritual assessment tools by asking experts in
Native culture to evaluate--from a Native perspective--the set's
degree of cultural consistency, strengths, limitations, and areas
needing improvement. In terms of cultural consistency, the results
suggest that the set is moderately consistent with Native culture.
Spiritual histories ranked highest in congruency with Native culture,
whereas spiritual genograms ranked lowest, although all the instruments
fell on the more consistent end of the scale.
Central strengths of the instruments were their capability to
explore a foundational dimension of Native American culture and their
flexibility. The limitations of the set included the complexity of some
of the instruments (particularly spiritual genograms and ecograms), the
language used to administer the assessments, the personal nature of many
Native spiritual practices, and the capability of practitioners to
administer the assessments. Areas for improvement generally built on
these limitations. To enhance the cultural utility of the instruments,
respondents recommended administering the assessment using common Native
terms, additional practitioner training, and validation of the
instruments with individual tribal cultures.
These findings build on and extend the existing literature in a
number of ways. For example, many respondents indicated that some of the
instruments were relatively complex. This finding was not unexpected.
Relatively complex assessment instruments, such as spiritual genograms
and eco-maps, are often viewed less favorably by many populations
(Frame, 2003; Hodge, 2005c). In contrast, verbally based spiritual
histories are congruent with the practice of oral storytelling found
among many Native tribes (Gesino, 2001; Napoli, 1999).
The results also confirm the important role that assessment can
play in operationalizing spiritual strengths among Native clients. As
noted in the introduction, spirituality and wellness are typically
intertwined in Native cultures (Cross, 2001; Gesino, 2001; Gone, 2004).
A culturally valid assessment plays a central role in helping
practitioners understand the interplay between these two constructs.
Yet, while affirming the importance of assessment, the results also
implicitly underscore the need for additional training. The findings
indicate that the validity of the assessment tools could be improved if
they were administered in a skilled manner. Put differently, the
culturally appropriate use of the instruments is dependent on
practitioners' attitudes and skill sets (Sue & Sue, 2008). If a
practitioner has the proper training to conduct an assessment in a
culturally competent manner, then the assessment instrument is more
likely to be perceived by clients as congruent with their cultural
beliefs and values.
Indeed, the results suggest that a valid assessment is predicated
on the development of cultural competency in the area of Native
spirituality or, perhaps more accurately, spiritual competency.
Spiritual competency can be understood as a form of cultural competency
that focuses on cultures animated by spirituality (Hodge &
Bushfield, 2006). In a manner analogous to common understandings of
cultural competence (Sue & Sue, 2008), spiritual competence can be
defined as an active, ongoing process characterized by three,
interrelated dimensions: (1) a growing awareness of one's own
value-informed worldview and its associated assumptions, limitations,
and biases; (2) a developing, empathic understanding of a client's
spiritual worldview that is devoid of negative judgment; and (3) an
increasing ability to design and implement intervention strategies that
are appropriate, relevant, and sensitive to the client's worldview
(Hodge & Bushfield, 2006).
Ideally, spiritual competency should be developed with each Native
culture. An assessment procedure that resonates with members of one
tribal culture may be incongruent with members of a different tribe
(Goldston et al., 2008). Although commonalities exist across tribes,
each assessment should be contextualized, with consideration given to
the values held by individuals, their families, clans, and tribes.
The issue of training is particularly salient given that most
social workers report being exposed to minimal, if any, content on
spirituality and religion during their graduate educations (Sheridan,
2009). The present research on the topic indicates that most social
workers have not been adequately prepared to conduct spiritual
assessments. In light of insufficient graduate training, the concerns
identified in this study become especially significant.
Conducting assessments with instruments that lack validity, or with
an insufficient level of spiritual competency, can damage or terminate
the practitioner-client relationship and accentuate clients'
problems (Cross, 2001; Gone, 2004;Weaver, 2005). Yet, in spite of the
risks to clients, studies indicate that most social workers affirm the
importance of, and have conducted, spiritual assessments in practice
settings (Sheridan, 2009). In line with this view, the Joint Commission
has revised its accreditation standards to require spiritual assessments
in behavioral health organizations providing addiction services,
hospitals, and other health care settings frequented by Native Americans
(Hodge, 2006; Koenig, 2007). If practitioners are going to conduct
spiritual assessments, it is critical that they administer such
assessments in a way that helps, rather than harms, clients. The
findings in this study represent one step toward the former end.
LIMITATIONS
The present results and subsequent discussion should be understood
in the context of this study's limitations. Generalization of the
findings is precluded by the use of a nonprobability sampling
methodology. Although the use of a hybrid purposive/ snowball sampling
strategy limits generalizibility, it should also be noted that this
methodology choice is appropriate in light of the few individuals with
specialized knowledge of Native American culture (Babble, 2007).
The preponderance of social workers in the sample may have biased
the results. By virtue of their professional socialization, social
workers may have a unique perspective on the topic. Further, no attempt
was made to delineate the specific values--apart from an emphasis on
spirituality--that serve to distinguish Native Americans as a culture.
This was deemed unnecessary given the respondents' status as
experts in Native culture. Yet, without delineated values, each
individual likely evaluated the instruments from a slightly different
perspective.
Another limitation is the small size of the sample relative to the
number of Native American tribes in the United States. As implied
earlier, surveying experts affiliated with a different constellation of
tribes might have produced different results (Goldston et al., 2008).
Additional validation studies are needed. In keeping with the results,
future researchers might validate the instruments with individual tribal
groups.
As counterpoints to the limitations that stem from the small sample
size, a couple of issues might be noted. First, the sample was similar
in size to those in previous, related research (Weaver, 1999, 2000).
Second, the tribes included in the study are among the largest in the
United States. Although these factors do not mitigate the need for
further research, they do suggest that the results may have some degree
of utility in terms of helping practitioners to conduct spiritual
assessments with Native clients.
CONCLUSION
Growing recognition exists among mental health professionals that
traditional beliefs and practices play an instrumental role in
engendering wellness among Native Americans (Goldston et al., 2008). To
operationalize these strengths, a spiritual assessment is often required
(Cross, 1997; Gesino, 2001). Given the lack of validated qualitative
instruments, this study sought to provide a degree of preliminary
validity for a complementary set of spiritual assessment tools.
Although verbally based spiritual histories recorded the highest
degree of culturally congruency, all of the measures recorded passable
levels of consistency. The set gives practitioners some flexibility in
assessment. No single assessment approach suits every situation.
Different instruments can be used to assess different dimensions of
client spirituality, depending on the needs and interests of clients and
practitioners in a given context. Readers interested in the various
approaches might consult other articles for more information about
culturally validated brief assessments (Hodge & Limb, 2010),
spiritual histories (Hodge & Limb, 2009a), spiritual lifemaps (Limb
& Hodge, 2007), spiritual genograms (Limb & Hodge, 2010),
spiritual eco-maps (Hodge & Limb, 2009b), and spiritual ecograms
(Limb & Hodge, 2011).
Before a spiritual assessment is conducted, however, practitioners
would benefit from considering their level of spiritual competency with
the Native cultures they are likely to encounter. Although the choice of
instrument is important, a practitioner's level of spiritual
competency is intrinsically linked to a successful, culturally
appropriate assessment.
REFERENCES
American Psychiatric Association. (2000). Diagnostic and
statistical manual of mental disorders (4th ed., text rev.).
(2000).Washington, DC: Author.
Armstrong, K. (2000). The battle for God. New York: Alfred A.
Knopf.
Babbie, E. (2007). The practice of social research (11th ed.).
Belmont, CA:Thomson/Wadsworth.
Coates, J., Gray, M., & Hetherington, T. (2006). An
"ecospiritual" perspective: Finally, a place for indigenous
approaches. British Journal of Social Work, 36, 381-399.
Cross, T. (1997). Understanding the relational worldview in Indian
families. Pathways Practice Digest, 12(4). Retrieved from
http://www.nicwa.org/services/techassist/worldview/worldview.htm
Cross, T. (200l). Spirituality and mental health: A Native American
perspective. Focal Point, 15(2), 37-38.
Denscombe, M. (2006).Web-based questionnaires and mode effect: An
evaluation based on completion rates and data contents of near-identical
questionnaires delivered in different modes. Social Science Computer
Review, 24, 246-254.
Denzin, N. K., & Lincoln, Y. S. (Eds.). (2003). The landscape
of qualitative research: Theories and issues (2nd ed.). Thousand Oaks,
CA: Sage Publications.
Dye, J. E, Schatz, I. M., Rosenberg, B.A., & Coleman. (2000).
Constant comparison method: A kaleidoscope of data. Qualitative Report,
4(1/2). Retrieved from http://www.nova.edu/ssss/QR/QR4-1/dye.html
Ellis, A. (1980). Psychotherapy and atheistic values: A response to
A. E. Bergin's "Psychotherapy and religious values."
Journal of Consulting and Clinical Psychology, 48, 635-639.
Fetzer Institute. (1999). Multidimensional measurement of
religiousness/spirituality for use in health research. Retrieved from
http://www.fetzer.org/component/content/ article/18-main/248-dses
Foster, S. L., & Mash, E.J. (I 999). Assessing social validity
in clinical treatment research: Issues and procedures. Journal of
Consulting and Clinical Psychology, 67, 308-319.
Frame, M.W. (2003). Integrating religion and spirituality into
counseling. Pacific Grove, CA: Brooks/Cole.
Fuller-Thomson, E., & Minkler, M. (2005). American
Indian/Alaskan Native grandparents raising grandchildren: Findings from
the Census 2000 Supplementary Survey. Social Work, 50, 131-139.
Gesino, J. P. (2001). Native Americans: Oppression and social work
practice. In G. A. Appleby, E. Colon, & J. Hamilton (Eds.),
Diversity, oppression, and social functioning (pp. 109-130). Needham
Heights, MA: Allyn & Bacon.
Gilgun, J. F. (2002). Completing the circle: American Indian
medicine wheels and the promotion of resilience of children and youth in
care. Journal of Human Behavior in the Social Environment, 6, 65-84.
Gilligan, C. (1993). In a different voice: Psychological theory and
women's development. Cambridge, MA: Harvard University Press.
Goldston, D. B., Molock, S. D., Whitbeck, L. B., Murakami, J. L.,
Zayas, L. H., & Hall, G.C.N. (2008). Cultural considerations in
adolescent suicide prevention and psychological treatment. American
Psychologist, 63, 14-31.
Gone, J. P. (2004). Mental health services for Native Americans in
the 21st century United States. Professional Psychology: Research and
Practice, 35, 10-18.
Graham, T.L.C. (2002). Using reasons for living to connect to
American Indian healing traditions. Journal of Sociology and Social
Welfare, 29, 55-75.
Green, J.W. (1999). Cultural awareness in the human services: A
multi-ethnic approach (3rd ed.). Needham Heights, MA: Allyn & Bacon.
Gresham, F. M., & Lopez, M. F. (1996). Social validation: A
unifying concept for school-based consultation research and practice.
School Psychology Quarterly, 11, 204-227.
Hill, P. C., & Hood, R.W. (Eds.). (1999). Measures of
religiosity. Birmingham, AL: Religious Education Press.
Hodge, D. R. (2001a). Spiritual assessment: A review of major
qualitative methods and a new framework for assessing spirituality.
Social Work, 46, 203-214.
Hodge, D. R. (2001b). Spiritual genograms: A generational approach
to assessing spirituality. Families in Society, 82, 35-48.
Hodge, D. R. (2004). Spirituality and people with mental illness:
Developing spiritual competency in assessment and intervention. Families
in Society, 85, 36-44.
Hodge, D. R. (2005a). Developing a spiritual assessment toolbox: A
discussion of the strengths and limitations of five different assessment
methods. Health & Social Work, 30, 314-323.
Hodge, D. R. (2005b). Spiritual assessment in marital and family
therapy: A methodological framework for selecting between six
qualitative assessment tools. Journal of Marital and Family Therapy, 31,
341-356.
Hodge, D. R. (2005c). Spiritual ecograms: A new assessment
instrument for identifying clients' spiritual strengths in space
and across time. Families in Society, 86, 287-296.
Hodge, D. R. (2005d). Spiritual life maps: A client-centered
pictorial instrument for spiritual assessment, planning, and
intervention. Social Work, 50, 77-87.
Hodge, D. R. (2006). A template for spiritual assessment: A review
of the JCAHO requirements and guidelines for implementation. Social
Work, 51, 317-326.
Hodge, D. R., & Bushfield, S. (2006). Developing spiritual
competence in practice. Journal of Ethnic and Cultural Diversity in
Social Work, 15, 101-127.
Hodge, D. R., & Gillespie, D. F. (2007). Phrase completion
scales: A better measurement approach than Likert scale? Journal of
Social Service Research, 33(4), 1-12.
Hodge, D. R., & Limb, G. E. (2009a). Spiritual histories and
Native Americans: A mixed method validation study. Journal of Social
Service Research, 35, 285-296.
Hodge, D. R., & Limb, G. E. (2009b). Establishing the
preliminary validity of spiritual eco-maps with Native Americans.
Clinical Social Work Journal, 37, 320-331.
Hodge, D. R., & Limb, G. E. (2010). Native Americans and brief
spiritual assessment: Examining and operationalizing the Joint
Commission's assessment framework. Social Work, 55, 297-307..
Hodge, D. R., & Williams, T. R. (2002). Assessing African
American spirituality with spiritual eco-maps. Families in Society, 83,
585-595.
Jordan, C., & Hoefer, R. A. (2001). Reliability and validity in
quantitative measurement. In B.A. Thyer (Ed.), The handbook of social
work research methods (pp. 53-68). Thousand Oaks, CA: Sage Publications.
Kaplowitz, M. D., Hadlock, T. D., & Levine, R. (2004). A
comparison of Web and mail survey response rates. Public Opinion
Quarterly, 68, 94-101.
Koenig, H. G. (2007). Spirituality in patient care (2nd ed.).
Philadelphia: Templeton Foundation Press.
Lane, K. L., & Frankenberger, M. B. (2004). School-based
interventions: The tools you need to succeed. New York: Allyn &
Bacon.
Limb, G. E., & Hodge, D. R. (2007). Developing spiritual
lifemaps as a culture-centered pictorial instrument for spiritual
assessments with Native American clients. Research on Social Work
Practice, 17, 296-304.
Limb, G. E., & Hodge, D. R. (2008). Developing spiritual
competency with Native Americans: Promoting wellness through balance and
harmony. Families in Society, 89, 615-622.
Limb, G. E., & Hodge, D. R. (2010). Helping child welfare
workers improve cultural competence by utilizing spiritual genograms
with Native American families and children. Children and Youth Services
Review, 32, 239-245.
Limb, G. E., & Hodge, D. R. (2011). Utilizing spiritual
ecograms with Native American families and children to promote cultural
competence in family therapy. Journal of Marital and Family Therapy,
37(3), 81-94.
Lowery, C.T. (1999).American Indian perspectives on addiction and
recovery. Health & Social Work, 23, 127-135.
Napoli, M. (1999).The non-Indian therapist working with American
Indian clients: Transference--countertransference implications.
Psychoanalytic Social Work, 6, 25-47.
Pace, T. M., Robbins, R. R., Choney, S. K., Hill, J. S., Lacey, K.,
& Blair, G. (2006). A cultural-contextual perspective on the
validity of the MMPI-2 with American Indians. Cultural Diversity and
Ethnic Minority Psychology, 12, 320-333.
Padgett, D. K. (2008). Qualitative methods in social work research
(2nd ed.).Thousand Oaks, CA: Sage Publications.
Sheridan, M. (2009). Ethical issues in the use of spiritually based
interventions in social work practice: What we are doing and why.
Journal of Religion and Spirituality in Social Work, 28(1/2), 99-126.
Solano-Flores, G., & Nelson-Barber, S. (2001). On the cultural
validity of science assessments. Journal of Research in Science
Teaching, 38, 553-573.
Stone, R.A.T., Whitbeck, L. B., Chen, X., & Johnson, K.
(2005).Traditional practices, traditional spirituality, and alcohol
cessation among American Indians. Journal of Studies on Alcohol, 67,
236-244.
Sue, D., & Sue, D. (2008). Counseling the culturally diverse:
Theory and practice (5th ed.). Hoboken, NJ: John Wiley & Sons.
Visser, P. S., Krosnick, J. A., & Lavrakas, P.J. (2000). Survey
research. In H.T. Reis & C. M. Judd (Eds.), Handbook of research
methods in social and personality psychology (pp. 223-252). New York:
Cambridge University Press.
Weaver, H. N. (1999). Indigenous people and the social work
profession: Defining culturally competent services. Social Work, 44,
217-225.
Weaver, H. N. (2000). Culture and professional educators: The
experiences of Native American social workers. Journal of Social Work
Education, 36, 415-428.
Weaver, H. N. (2002). Perspectives on wellness: Journeys on the red
road. Journal of Sociology and Social Welfare, 29, 5-15.
Weaver, H. N. (2005). Explorations in cultural competence. Belmont,
CA: Thomson-Brooks/Cole.
Wolf, M. (1978). Social validity: The case for subjective
measurement. Journal of Applied Behavior Analysis, 11, 203-214.
Yellow Bird. (2004). Cowboys and Indians: Toys of genocide, icons
of American colonialism. Wicazo Sa Review, 19(2), 33-48.
Zvolensky, M.J., McNeil, D.W., Porter, C. A., & Stewart, S. H.
(2001). Assessment of anxiety sensitivity in young American Indians and
Alaska Natives. Behaviour Research and Therapy, 39, 477-493.
Original manuscript received December 2, 2008
Final revision received October 19, 2009
Accepted January 14, 2010
David R. Hodge, PhD, is associate professor, School of Social Work,
Arizona State University, Phoenix, and senior nonresident fellow,
Program for Research on Religion and Urban Civil Society, University of
Pennsylvania, Philadelphia. Gordon E. Limb, PhD, is associate professor
and director, School of Social Work, Brigham Young University, Provo,
UT. Address correspondence to David R. Hodge, Arizona State University,
School of Social Work, Mail Code 3251, 4701 West Thunderbird Road,
Glendale, AZ 85306-4908.
Table 1: Demographic
Characteristics (N = 50)
Characteristic M SD n %
Age (years) 49.92 11.71
Gender
Female 32 64.0
Male 18 36.0
Tribal nation
Lakota 4 8.0
Navajo/Dine 4 8.0
Chippewa/Ojibwa 6 12.0
Cherokee 5 10.0
Other tribal affiliation 17 34.0
Mixed blood/American Indian 6 12.0
Non-Native 8 16.0
Area currently residing
Northwest 7 14.0
Southwest 9 18.0
West 14 28.0
Midwest 14 28.0
East 6 12.0
Spiritual/religious affiliation
Traditional (Native) 22 44.0
Christian 17 34.0
Other 9 18.0
None 2 4.0
Years of professional experience 16.97 10.21
Social work degree (yes) 45 90.0
Years in social work (n = 45) 18.00 9.97
Table 2: Consistency with Native
American Culture (N = 50)
Instrument M SD Mode
Brief assessment tool 5.42 2.50 5
Comprehensive assessment
Spiritual history 7.06 2.49 9
Spiritual lifemap 6.58 2.67 8
Spiritual genogram 5.40 2.94 5
Spiritual eco-map 6.36 2.72 5/8 (a)
Spiritual ecogram 5.96 2.75 8
Overall set 6.06 2.21 7
Note: All instruments were assessed on a scale ranging from 0 =
absence of consistency with Native American culture to 10 = complete
consistency with Native American culture.
(a) The values 5 and 8 were both selected with the same degree
of frequency.
