Native Americans and brief spiritual assessment: examining and operationalizing the joint commission's assessment framework.

Hodge, David R. ; Limb, Gordon E.

The largest and most prominent health care accrediting organization in the United States is the Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations or, more commonly, as JCAHO (2009). The interrelationship between the Joint Commission and the field of social work is evidenced by the fact that NASW (2004) maintains a partnership with the Joint Commission. In addition to accrediting most of the nation's hospitals, the Joint Commission also accredits thousands of other organizations providing health and mental health services.

At the turn of the century, the Joint Commission revised its accreditation standards to require the administration of a spiritual assessment (Hodge, 2006b). Spiritual assessments are now mandated in numerous settings, including hospitals, home care organizations, long-term care facilities, and behavioral health care organizations providing addiction services. This requirement is consistent with the views of most social work practitioners. Research has repeatedly found that the majority of practitioners affirm the importance of conducting a spiritual assessment in practice settings (Canda & Furman, 1999; Carlson, Kirkpatrick, Hecker, & Killmer, 2002; Heyman, Buchanan, Musgrave, & Menz, 2006; Murdock, 2005; Sheridan, 2004; Sheridan & Amato-von Hemert, 1999; Stewart, Koeske, & Koeske, 2006).

As Weaver (2004) observed, helping professionals are disproportionately likely to encounter Native American clients in mental health settings. Due to a number of factors, including a history of oppression (Weaver & Brave Hart, 1999), Native Americans are disproportionately likely to wrestle with mental health challenges (Beals et al., 2005; Harris, Edlund, & Larson, 2005; Stiffman et al., 2006).

Higher rates of challenges result in higher levels of service use. Harris et al. (2005) found that among those with one or more mental health symptom (N = 406), 42.32 percent of Native Americans had used mental health services, a percentage significantly higher than those for African Americans, Asians, and Latinos. Indeed, in absolute terms, Native Americans recorded the highest percentage of mental health service use across all groups surveyed (Harris et al., 2005).

In theory, the Joint Commission's spiritual assessment requirements represent a positive development for Native American users of health care services. Although no single Native culture exists (Fuller-Thomson & Minkler, 2005), a number of values are shared among many tribes. Among these commonalities is a shared emphasis on spirituality (Cross, 2001).

Indeed, spirituality is widely cited as a particularly important component of many Native cultures (Frame, 2003; Gesino, 2001 ; Graham, 2002). Furthermore, spirituality is commonly viewed as essential to the promotion of health and wellness (Gilgun, 2002; Lowery, 1999). In other words, spirituality is typically viewed as a critical strength that must be operationalized to address the challenges Native people face (Cross, 1997; Limb & Hodge, 2008; Stone, Whitbeck, Chen, & Johnson, 2005).

Concurrently, it should be noted that common Native understandings of spirituality differ from those affirmed in the dominant secular culture (Cross, 2001). This raises the possibility that the spiritual assessment requirements developed by the Joint Commission may conflict with Native understandings of spirituality. All human constructions tend to reflect the values of their designers (Tjeltveit, 1999). Assessment frameworks developed by dominant groups often implicitly reflect value systems that conflict with the values of minority groups (Gilligan, 1993).

Indeed, numerous authors have argued that Western therapeutic approaches conflict with many Native worldviews (Coates, Gray, & Hetherington, 2006; Yellow Bird, 2004). Consequently, services provided by social workers and other mental health professionals are often perceived to be, at best, ineffective (Walls, Johnson, Whitbeck, & Hoyt, 2006). At worst, the use of Enlightenment-based frameworks may represent an unethical imposition of culturally foreign values (Gone, 2004; Weaver, 2005).

In a similar manner, the Joint Commission's assessment framework--developed and operationalized in a Western ideological context--may also be ineffective or even harmful when used with Native clients. This possibility is particularly disconcerting given the fact that the spiritual assessment is required and the high levels of mental health service use among Native American clients. Members of a historically disadvantaged population in need of mental health services (Harris et al., 2005) may face the possibility of having an oppressive framework imposed on them, further accentuating their mental health needs.

Before delineating research questions to address these concerns, we review the Joint Commission's spiritual assessment framework along with one attempt to operationalize the framework in the form of an assessment protocol.

JOINT COMMISSION'S SPIRITUAL ASSESSMENT FRAMEWORK

As implied earlier, the Joint Commission requires the administration of what might be called a "brief spiritual assessment" in many settings, including hospitals and behavioral health organizations providing addiction services (Hodge, 2006b). Regardless of the setting, the same basic framework is used in all situations. At a minimum, the assessment should consist of an exploration of the following three areas: (1) denomination; (2) spiritual beliefs; and (3) important spiritual practices, if any.

The purpose of the assessment is twofold (Hodge, 2006b). First, the information is used to determine the impact, if any, on the services being provided. In some cases, client spirituality may be nonexistent or irrelevant to service provision. However, in other cases, client spirituality may affect service provision. As the NASW (2001) Standards for Cultural Competence in Social Work Practice imply, clients' spiritual beliefs often inform numerous areas that should be considered in the provision of mental health services.

The second reason for conducting a brief assessment is to determine whether an additional, more comprehensive spiritual assessment is needed (Hodge, 2006b). If client spirituality affects service provision, then what might be called a "comprehensive spiritual assessment" may be needed to explore harriers that might hinder service provision and to identify spiritual strengths (Hodge, 2005). In terms of barriers, clients' spiritual beliefs may preclude them from affiliating with certain types of therapeutic groups (Hodge & Nadir, 2008; JCAHO, 2003). In a similar manner, spirituality can often be marshaled to help clients cope with difficult situations or to ameliorate the challenges they encounter (Hodge, 2006a; Richards & Bergin, 2000; Van Hook, Hugen, & Aguilar, 2001).

Although the Joint Commission offers some sample questions to provide a sense of the type of issues that might be explored when conducting a spiritual assessment, it does not supply a specific protocol to operationalize the framework discussed earlier (Hedge, 2006b). One set of questions that might be used to meet the Joint Commission's assessment requirements is listed in Table 1. These questions, however, much like the Joint Commission's framework, were not necessarily developed with Native populations in mind.

Due to the potential lack of congruence of both the assessment framework and its operationalization with common Native American values, this study sought to answer two multifaceted questions. First, regarding the Joint Commission's spiritual assessment framework, how consistent is this concept with Native American culture, and what are its strengths and limitations? Second, regarding the assessment protocol presented in Table 1, how consistent are these questions with Native American culture, and how might they be improved or changed to be more valid, relevant, and consistent with Native culture?

METHOD

Participants

As part of a larger project designed to validate a complementary family of spiritual assessments instruments, a diverse sample of experts in Native American culture was solicited (Pace et al., 2006).

To identify individuals with specialized knowledge of Native Americans, a hybrid purposive-snowball sampling strategy was used (Babbie, 2007). One of the authors, a Native American academic with extensive practice and research experience with Native populations, contacted a number of potential participants by e-mail. In turn, these experts were asked to identify other experts, who were also subsequently invited to participate in the study.

Sixty-seven Native American experts were identified using this strategy, of whom 50 agreed to participate in the study--a response rate of 74.63 percent, which is generally considered to be very good (Babbie, 2007). As implied above, all 50 participants had significant levels of expertise in Native culture, derived from either direct practice or research. The sample size is consistent with previous, related research (Weaver, 1999, 2000).

A relatively wide range of tribal, geographic, and spiritual affiliations existed among the participants (see Table 2), which enhances the validity of the results by incorporating diverse perspectives into the study. The mean age was approximately 50 years, close to two-thirds of participants were female, and 90 percent had a social work degree. The average length of professional experience was approximately 17 years, suggesting that the participants were well situated to complete the survey instrument.

Apparatus

In keeping with the foregoing discussion, the mixed-method survey incorporated a review of the Joint Commission's spiritual assessment requirements, a description of its twofold purpose, and the question protocol presented in Table 1. After description of the requirements and purpose for conducting an assessment, individuals were asked to assess the degree of consistency of the Joint Commission's framework with Native American culture. Responses were marked on an 11-point scale on which 0 corresponded to the complete absence of consistency with Native American culture and 10 corresponded to complete consistency with Native American culture (Hedge & Gillespie, 2005; Visser, Krosnick, & Lavrakas, 2000).

To clarify what was meant by the term "Native American culture," it was noted that many differences exist among Native American tribes. Concurrently, a number of beliefs, values, and practices are widely shared among Native Americans, which serves to demarcate 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."

After assessing degree of consistency of the Joint Commission's framework with Native American culture, individuals were presented with two open-ended qualitative questions. These questions explored the strengths and limitations of the brief assessment model in work with Native clients. The question concerning strengths asked, "In terms of working with Native Americans, what are the strengths of brief assessments?"

To address the second research question, we had the instrument delineate the question protocol presented in Table 1 while noting that the questions represented "one way to operationalize" the Joint Commission's assessment requirements. Individuals were then asked to assess the overall consistency of the protocol with Native American culture using the 11-point scale discussed earlier. A subsequent item solicited comments about the protocol by asking, How could these questions be improved to be more valid, relevant, and consistent with Native American culture? In other words, are there other questions that might do a better job of assessing denomination, and important spiritual beliefs, and practices among Native Americans?

Procedures

The survey instrument was pilot tested with five individuals who attended an American Indian/ Alaska Native Social Work Educators Association meeting. They reviewed the instrument's content and design for clarity and assessed its face validity. Refinements were then made to the instrument on the basis of their feedback.

To minimize time requirements and facilitate completion of the survey, we placed the instrument online. Research examining the quality and reliability of Web- and paper-based surveys suggest that the data produced by the two approaches are comparable (Denscombe, 2006). A URL link to a site on which responses could be directly entered was e-mailed to participants. In appreciation for the time spent by busy Native American experts filling out the survey, each individual received a $50 honorarium on completing the survey.

Data Analysis

Quantitative responses were entered directly into an SPSS database. The data were cleaned, and associations were explored between these variables and the demographic variables reported in Table 2. For the qualitative items, we used a constant comparative methodology in which the data were examined for similarities, patterns, and common themes (Dye, Schatz, Rosenberg, & Coleman, 2000; Glaser & Strauss, 1967). In a recursive process, the emerging themes were continually compared with similar phenomena across survey instruments. Primary themes were identified, organized into "meaning clusters" when possible, and labeled. Direct quotations are used to highlight the resulting themes and meaning clusters.

In keeping with the two primary research questions, the results are reported in two subsections. The first reports the results related to the Joint Commission's assessment framework. The second reports the results related to the question protocol featured in Table 1.

RESULTS

Joint Commission's Assessment Framework

One quantitative and two qualitative questions were used to assess the framework's degree of cultural consistency as well as its strengths and limitations when used with Native clients. On the 0-to-10 scale measuring perceptions of cultural consistency, respondents recorded a value of roughly 5.5 (see Table 3). This value suggests that that the Joint Commission's spiritual assessment framework was perceived to be moderately consistent with Native American culture.

Possible associations between perceptions of cultural consistency and the demographic variables were explored. Analysis revealed that gender, age, and years of professional experience (among social workers and the sample as a whole) were unrelated to perceptions of consistency with Native American culture. This suggests that perceptions of the framework's consistency with Native culture were relatively stable across the surveyed demographic characteristics.

Individuals were asked an open-ended question about the strengths of the framework for working with Native American clients. Analysis revealed that most responses could be categorized into a single meaning cluster--that the framework represents a method of exploring an area of importance for many Native clients. Many responses emphasized the theme of importance. As one person commented, the assessment process brings "the element of spirituality into treatment, where it is an important dimension for many Native people." Others commented that the assessment process, in and of itself, implicitly communicates to clients that their spirituality is important. Another emphasized the role of context, stating that "if the questions are asked respectfully and honored, if the agency is responsive, it can be of tremendous importance to clients that their beliefs are taken seriously by providers."

Others made similar points but emphasized the theme of therapeutic benefit. One respondent observed that the assessment process "can improve the overall provision of services" by providing a forum in which Native clients can express their spirituality, enhancing trust and hope. Another said, Brief assessment can help guide the practitioner on how to approach his/her client in the most effective way possible. With Native Americans--because spirituality is so linked to Indian identity--it is critical that a practitioner understand as soon as possible what traditional beliefs are relevant to that person in order to tailor a treatment plan that the person will trust and follow. This will help overcome the inherent skepticism many Natives have of European-style health care approaches.

The second qualitative question asked about the limitations regarding work with Native American clients. As was true with the first question, analysis revealed that most responses could be categorized into a single meaning cluster--in this case, trust. Multiple themes, however, were evident. Many respondents underscored the need for Native clients to develop trust in mental health professionals before proceeding with any form of spiritual assessment. As one person stated, "Trust has to be built before any of this information will be shared."

Others noted that traditional forms of spirituality are often very sacred in nature and that asking about such areas before rapport has been developed can be perceived as invasive. As one expert said, Spirituality is a very personal thing for most people [who] are of Native cultural backgrounds. Assessment should always be based in a relationship of trust, which takes time to build. Even asking about a "denomination" can create barriers in the [therapeutic] relationship.

Echoing this concern, another person noted the potential for offending or alienating the client "by asking the wrong question or appearing to pry into a very personal realm."

Others areas of potential concern included the reading level required if the framework was operationalized in written form; lack of familiarity among mental health professionals with various expressions of spirituality, including knowing that some information can only be shared within the particular tribal group; and the congruence of the brief framework with the Native emphasis on story. Regarding the last concern, one respondent noted that many Native Americans respond to questions with a story, which may not be "brief" in length and the content of which might not be understood by practitioners unfamiliar with common Native values.

Assessment Protocol

To assess the degree to which the question protocol presented in Table l is consistent with Native American culture, we used a quantitative item similar to that discussed earlier. A score of 5.52 was recorded by the group as a whole on the 0-to-10 scale. It is interesting to note that the most frequently selected number was 9, indicating that a number of respondents perceived the protocol to be almost completely consistent with Native American culture.

Perceptions of the Joint Commission's framework's degree of cultural consistency were strongly correlated with perceptions of the protocol's degree of cultural consistency (r = .565, p [less than or equal to] .001). Thus, respondents who tended to view the framework as valid with Native culture also tended to view the protocol in similar terms. Although gender and age were unassociated with perceptions, years of professional experience was moderately related to perceptions of cultural consistency among the sample as a whole (r = -.381,p = .007). Among social workers, the relationship was even stronger (r = -.454, p = .002), and age was also significant (r = -.334, p = .025). This finding suggests that those with more professional experience tended to view the protocol as less consistent with Native culture.

However, use of the partial correlation procedure to control for age revealed that the relationship between years of experience and perceptions of cultural consistency was no longer significant. This was the case for both the sample as a whole (r = -. 198,p = .176) and for social workers (r = -.084,p = .587); with age controlled for, the relationship between years of professional experience and perceptions of cultural consistency disappeared. In other words, our finding here suggests that professional experience is unrelated to perceptions of the protocol's level of consistency with Native American culture when age is taken into account.

To improve the operationalization of the Joint Commission's assessment framework, we used a qualitative item to explore how the questions featured in Table 1 could be altered or reworked to be more valid, relevant, and consistent with Native American culture. In contrast to what happened with the earlier open-ended items, analysis failed to reveal a single prominent meaning cluster around which many related themes could be grouped. Rather, a wide range of themes emerged.

In keeping with the sensitive nature of Native spirituality, some respondents underscored the need to secure permission and explain the underlying rational for administering an assessment before proceeding. In place of closed-ended questions, some suggested using more conversational, open-ended questions. Others recommended breaking the first question up into separate items--one focusing on spirituality, the other on religion--because of the different meanings each term can evoke. Likewise, regarding question 3, some experts suggested breaking the item into two questions--one exploring beliefs, the other exploring practices.

Some experts also questioned the use of particular terms and phrases, suggesting that more accessible language be used. For example, some respondents indicated that the term "faith community" would not be familiar with some Native clients. Although mentioned less often, other experts raised questions about the terms "spiritual practices" and "resources," indicating that such language may not be understood by all Native Americans. In keeping with this line of thought, some recommended using terms that resonate with a wide cross-section of Native Americans--such as "ceremonies," "sacred practices," "Creator," and "medicine man"--arguing that such language may help create space for traditional expressions of spirituality in addition to being more readily understood. In a similar manner, along with the use of the term "community," some also suggested including words such as "family" and, less often, "tribe" or "clan."

Some respondents found the questions too direct or too invasive and recommended very indirect questions that only implicitly addressed the issue of spirituality by, for example, asking about clients' degree of familiarity with their own traditions or their level of participation in ceremonies or dances. Other themes that emerged, which were not necessarily linked to questions, were as follows: the holistic, pervasive nature of many forms of Native spirituality, in which life cannot be compartmentalized into spiritual and secular dimensions; that some Native Americans attend a Christian church, or churches, in tandem with engaging in traditional Native practices; and the importance of mental health professionals maintaining an attitude of humility and openness during the assessment process. Various experts also offered a number of alternative questions or protocols that reflected the points mentioned here.

It should be noted that some experts endorsed the protocol presented in Table 1 in its current state or with slight modifications. For example, as one expert said, "If question 1 is answered in the affirmative, then one could simply ask, 'In what ways?' or 'Please elaborate on the ways spirituality is part of your life.'"

DISCUSSION

Since the turn of the century, the Joint Commission has required spiritual assessments in hospitals and many other mental health settings frequented by Native Americans (Hodge, 2006b). Despite high levels of service use by Native clients (Harris et al., 2005; Weaver, 2004), little, if any, research has been conducted to determine how to implement this new requirement with Native Americans (Weaver, 1999, 2005). Using a sample of 50 identified experts in Native American culture, this study addressed this gap in the literature by exploring the cultural consistency, strengths, and limitations of the Joint Commission's spiritual assessment framework. To ensure that the framework is implemented in a manner that is congruent with Native American values, the study also sought to identify an assessment protocol that is valid, relevant, and consistent with Native American culture.

The Joint Commission's spiritual assessment framework was perceived to be moderately consistent with Native American culture. The 5.42 score on the 0-to-10 scale indicated that the experts believed that the framework fell toward the consistency end of the continuum, although some degree of concern is also suggested. Two open-ended questions exploring the framework's strengths and limitations helped shed light on the numerical ranking.

Consistent with prior work (Limb & Hodge, 2008; Lowery, 1999; Weaver, 2005), spirituality was cited as an instrumental component of Native American culture. Consequently, the results indicate that it is critical for both clients and practitioners that this strength be understood if services are to be effective (Cross, 2001). This finding is in sync with the Joint Commission's underlying rationale for requiring spiritual assessments (Hodge, 2006b). It is interesting to note that it is the very importance of spirituality to Native Americans that animated at least some of the limitations.

More specifically, because spirituality is so instrumental in Native American worldviews, it is imperative that mental health practitioners cultivate a therapeutic relationship with Native clients that is permeated by trust and respect. Exploring client spirituality before sufficient rapport has been developed, or in a disrespectful manner, may damage the therapeutic relationship as this subject matter is often one of extreme sensitivity. Put differently, the Joint Commission's framework is detrimental in the sense that it forces practitioners to explore an emotionally charged area, an area in which most practitioners have had little, if any, training during their graduate educations (Canda & Furman, 1999; Heyman et al., 2006; Murdock, 2005; Sheridan, 2004). As one respondent who selected a medium score on the scale implied, if the framework is not operationalized and implemented in the proper manner, harm may be done to clients.

The question protocol presented in Table 1 represents one way to operationalize the Joint Commission's requirements. As was the case with the Joint Commission's framework, respondents reported that the protocol leaned toward consistency with Native American culture. Perceptions of the two constructs were highly correlated, signifying that those who believed the framework was consistent with Native culture also tended to believe that the protocol was consistent. Furthermore, the mode was 9, indicating that a substantial number of experts viewed the protocol as highly consistent with Native culture.

Conversely, a number of other experts recorded lower scores, implying that other protocols also might be useful. Two alternative protocols that have been synthesized from various options provided by respondents are presented in Table 4. The first protocol depicts a set of open-ended items that are designed to foster conversation in a very nondirective manner. Individuals are allowed to define key concepts, such as spirituality, religion, and the type of formalized expression of their spirituality or religion (if any) in which they participate. In obtaining answers to these questions, practitioners should generally be able to satisfy the Joint Commission's requirements regarding denomination, spiritual beliefs, and spiritual practices.

The Joint Commission's requirements can also be fulfilled through use of the second protocol in Table 4. In contrast to the previous set of items, these questions reflect a traditional Native perspective. With this protocol, it is assumed that the clients' "denomination" is traditional Native spirituality rather than a specific denomination such as the Catholic Church. Accordingly, the questions focus on spiritual beliefs and practices.

As is the case with all three protocols, how clients respond to the first question shapes how the subsequent questions will be phrased (Hodge, 2004). As one expert suggested, if the answer to the opening question indicates a traditional orientation, then subsequent questions should be constructed to reflect this perspective. If clients answer question 4 in Table 1 by indicating that they attend a Native American church, for instance, then question 5 would use this term rather than "faith community" or some other variation.

Accordingly, practitioners might familiarize themselves with a variety of questions. Ideally, unique protocols would be developed for each client depending on his or her spiritual and religious beliefs. Terms, beliefs, and practices that surface in earlier questions should be incorporated into subsequent questions. As a number of experts implied, the use of language drawn from clients' spiritual worldviews helps to legitimize the belief system and builds trust.

Other suggestions for fostering trust were also suggested and warrant highlighting. As implied by the opening comments for each protocol featured in Table 4, a number of experts noted the importance of creating the proper context before proceeding with a spiritual assessment. One expert recommended beginning by acknowledging that spiritual beliefs and practices are very personal, asking for forgiveness for asking questions that might be offensive, explaining the reasons for conducting an assessment, and asking for permission to proceed with an assessment. Echoing these comments, another respondent offered the following language as an example of how to begin the assessment: It used to be that social workers or healthcare providers did not really understand or appreciate the importance of spirituality [to] an individual's health and wellness. Today there is a greater respect for the role of spirituality and religion in supporting a person's well-being and even the well-being of his or her family and community. Because of this new sense of respect and understanding, I'd like to ask a few questions. Of course, you are free to not answer any that you don't feel comfortable answering or you feel are too personal. We can always discuss any of these things later [in the assessment, as issues or concerns come up].

Any such language, however, must be conveyed in a manner that reflects a genuine humility and openness. These characteristics engender trust and lay the foundation for the entire assessment.

As noted earlier, a brief spiritual assessment can lay the foundation for a subsequent comprehensive spiritual assessment. If a brief assessment reveals that spirituality intersects service provision, a comprehensive spiritual assessment may be warranted (Hodge, 2006b). Practitioners interested in conducting comprehensive spiritual assessments with Native clients may wish to familiarize themselves with the following family of tools. This diverse set of approaches to assessment includes one verbal tool--spiritual histories (Hodge & Limb, 2009b--and four diagrammatic tools--spiritual lifemaps (Limb & Hodge, 2007), spiritual eco-maps (Hodge & Limb, 2009a), spiritual genograms (Limb & Hodge, 2010), and spiritual ecograms (Limb & Hodge, in press). A preliminary degree of validity has been established with Native Americans for all five tools. Empirically based information on conducting spiritual assessments in a culturally competent manner may also be useful (Hodge & Limb, 2010).

Limitations

The Results and Discussion should be considered in light of this study's limitations. Given the limited number of individuals with specialized knowledge of Native American culture, the use of a hybrid purposive-snowball sampling strategy is appropriate (Babbie, 2007). However, the use of a nonprobability sampling methodology precludes generalization of the results beyond the present respondents.

Within the preview of nonprobability sampling strategies, the use of diverse participants can enhance the validity of the results by mitigating various biases (Babbie, 2007). For example, the diverse regional representation in this study helps to safeguard against any extant geographic bias. Yet, although the sample size was similar to those in previous, related research (Weaver, 1999, 2000), the relatively small size of the sample in relation to the number of Native tribes should also be considered a limitation. A larger sample, incorporating a more diverse array of tribal affiliations, might result in a somewhat different set of findings regarding the Joint Commission's framework and the operation of that framework in the form of assessment tools.

CONCLUSION

As Weaver (2005) observed, most assessment tools have not been developed or modified for use with Native Americans. Tools developed within the dominant secular ideological context must be tested to ensure that they are effective, rather than oppressive, when used with Native Americans (Weaver, 2005). Unfortunately, little empirical work of this type has appeared in the social work literature (Cross, 2001 ;Weaver, 1999).

This study advances the knowledge base in the area of spiritual assessment by identifying the cultural consistency, strengths, and limitations of the Joint Commission's assessment framework and providing culturally valid question protocols to operationalize the framework with Native clients. It is important to emphasize, however, that this is just a first step and that practitioners should exercise caution when using the tools discussed in this article because of the diversity that exists among Native tribes. Indeed, further studies must be conducted at the tribal level to ensure that the assessment tools are valid with various Native populations.

Original manuscript received May 22, 2007

Accepted January 23, 2009

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David R. Hodge, PhD, is assistant 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, School of Social Work, Brigham Young University, Provo, UT Address correspondence to David R. Hodge, Mail Code 3920, CoPP,, 411 North Central Avenue, Suite 800, Phoenix, AZ 85004-0689. Table 1: Brief Spiritual Assessment Protocol Developed for Use with the General Population 1. I was wondering if spirituality or religion is important to you? 2. In what ways does your spirituality help you cope with difficulties? 3. Are there certain spiritual beliefs and practices that you find particularly helpful in dealing with problems? 4. I was also wondering if you attend a church or some other type of spiritual community? 5. Do resources exist in your spiritual community that might be helpful to you? Source: Adapted with permission from "Spirituality and People with Mental Illness: Developing Spiritual Competency in Assessment and Intervention" by D. R. Hedge, 2004, Families in Society, 85, 36-44. Copyright 2004 by the Alliance for Children and Families. Table 2: Demographic Characteristics of Native American Experts (N = 50) Characteristic M SD n % Age (years) 49.92 11.71 Gender Female 32 64 Male 18 36 Tribal nation Lakota 4 8 Navajo/Dine 4 8 Chippewa/Ojibwa 6 12 Cherokee 5 10 Other tribal affiliation 17 34 Mixed blood/American Indian 6 12 Non-Native 8 16 Area currently residing Northwest 7 14 Southwest 9 18 West 14 28 Midwest 14 28 East 6 12 Spiritual/religious background Traditional (Native) 22 44 Christian 17 34 Other 9 18 None 2 4 Years of professional experience 16.97 10.21 Social work degree (yes) 45 90 Years in social work (n = 45) 18.00 9.97 Table 3: Perceptions of Consistency with Native American Culture Area M SD Min. Max. Mode Joint Commission's 5.42 2.20 0 10 6 spiritual assessment framework Question protocol 5.52 2.67 0 10 9 featured in Table 1 Note: Min. = minimum; Max. = maximum. Table 4: Alternative Spiritual Assessment Protocols Open-ended Protocol 1. Can you explain what spirituality means to you? What religion means to you? 2. How do these beliefs affect your everyday life? Your health? 3. To what extent do others in your family, clan, and tribe have similar beliefs? 4. Are there any formalized places or gatherings in your community for those who have similar beliefs? If so, what, if any, role do these places play in your life? Health? 5. When you face difficulties, how does your spirituality help you deal with the challenges? Traditional Protocol Without having to disclose private information about the traditional practices of your people, can you tell me: 1. What teachings about the Creator, the Great Spirit, or a higher power do you relate to? 2. In what ways do you participate in tribal ceremonies? 3. Are there certain sacred practices or ceremonies that you find helpful for healing? 4. Is there anyone who might be of help in the current situation, perhaps an elder, medicine man, or traditional healer?