Spirituality and People With Mental Illness: Developing Spiritual Competency in Assessment and Intervention

Hodge, David R

Abstract

Spirituality often plays a central role in helping people with mental illness cope and recover. Assessment provides a vehicle for understanding and utilizing clients' spiritual strengths, and, consequently, practitioners are increasingly asked to conduct a spiritual assessment. For example, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a major healthcare accrediting agency, now recommends that a spiritual assessment be conducted. This article provides a framework for an initial spiritual assessment that complies with the recent JCAHO (2002) recommendations. Suggestions for spiritually competent practice are provided, including guidelines for discerning authentic spiritual experiences from manifestations of mental illness that reflect spiritual content. The article concludes by reviewing a number of spiritual interventions that may flow from a spiritual assessment.

Recovery from serious mental illness occurs with frequency. Although traditionally the possibility of recovery from severe mental illness has been questioned, longitudinal studies indicate that partial and full recovery are often possible, even in the second and third decade of illness (DeSisto, Harding, McCormick, Ashikaga, & Brooks, 1999; Harding & Zahniser, 1994; Harding, Zubin, & Strauss, 1992). For example, among clients with schizophrenia, Harding and Zahniser (1994) reported that more than 50% experience significant improvement and/or recovery.

For many clients, spirituality plays an instrumental role in the recovery process (Fallot, 2001b; Sullivan, 1998). Although individuals such as Freud (1927/1964) and Ellis (1980) hypothesized that spirituality was associated with psychopathology, the empirical evidence has failed to support this assumption. Reviews of the research have consistently revealed a generally positive association between spirituality and various dimensions of mental health (Gartner, 1996; Koenig, McCullough, & Larson, 2001; Pargament, 1997; Plante & Sherman, 2001; Schumaker, 1992; Ventis, 1995). For instance, Koenig et al.'s (2001) review of over 1,000 studies revealed that spirituality was associated with increased adaptation to bereavement, selfesteem, social support, life satisfaction and happiness, hope and optimism, and purpose and meaning, in conjunction with decreased levels of anxiety, loneliness, and suicide.

In light of the fundamental role that spirituality often plays in clients' lives, growing recognition exists of the need to conduct at least a preliminary spiritual assessment (Plante & Sharma, 2001). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredits most hospitals in the United States, as well as a number of other mental health service providers. JCAHO now recommends that a spiritual assessment be undertaken with each client (JCAHO, 2002). Social workers, however, have received little training to assist them in conducting such an assessment (Canda & Furman, 1999). Furthermore, in spite of growing awareness of the importance of spirituality in clients' lives, little attention has been devoted to the role of spirituality in the lives of clients with mental illness (Fallot, 1998c).

To address the gap in the social work literature, this article aims to assist social workers with conducting assessments and planning interventions in a spiritually competent manner. After defining spirituality and religion, spirituality and its role in fostering recovery among people with mental illness is explored. A format for conducting a spiritual assessment that meets the JCAHO (2002) requirements is delineated along with material to assist practitioners in working with clients' spirituality with competency. This article concludes by reviewing a number of spiritual interventions that often flow from assessment that may be helpful for people struggling with mental illness.

Definitions

Spirituality and religion are generally conceptualized as distinct but overlapping constructs (Canda, 1997; Carroll, 1998; Koenig et al., 2001). For instance, Hodge (2000) defined spirituality as an individual's existential relationship with God (or perceived transcendence), whereas religion is defined as an institutionalized set of beliefs and practices that have been developed in community by people who share similar experiences of transcendent reality.

Debate exists over whether spirituality or religion is the broader term (Pargament, 1999). In this article, the usage of the original authors is followed when summarizing existing research. In general, however, spirituality is used as the more encompassing term. In other words, when spirituality is referred to, religion is also included as an expression of spirituality.

Spirituality Among People With Mental Illness

Although the data are limited, the extant research suggests that the salience of spirituality among individuals wrestling with mental disorders is similar to that of the general public (Fallot, 1998a), or perhaps somewhat higher (Baetz, Larson, Marcoux, Bowen, & Griffin, 2002; Neeleman & Lewis, 1994). Among a sample of adult psychiatric inpatients (N = 51) at a Midwest tertiary care hospital, 80% identified themselves as spiritual or religious (Fitchett, Burton, & Sivan, 1997). When asked how often they had attended religious services during the past year, 34% indicated they had attended weekly or more, and an additional 10% indicated once or twice a month. These responses are generally congruent with those of the general population, as recorded in the 1998 General Social Survey (J. A. Davis, Smith, & Marsden, 1998). Among a Canadian sample of consecutively admitted psychiatric inpatients (N = 88), the level of attendance at worship services was also comparable to the level among the general Canadian population (Baetz et al., 2002).

A study of psychiatric inpatients in Minnesota (N = 52) explored belief in God, the devil, an afterlife, Biblical miracles, Christ's return, and other widely held spiritual tenets (Kroll & Sheehan, 1989). As was the case with the above study, these authors found levels of affirmation that were comparable to those found among the general public. As implied in the introduction, it is important to note that the data do not support a link between spiritual content in psychotic delusions and religious activity or conservative spiritual beliefs (Koenig et al., 2001).

As occurs in other situations in which individuals face difficult circumstances (Pargament, 1997), clients facing the onset of mental illness may turn to their faith to cope. In other words, clients may deepen their spirituality to help them deal with their problems. This may account for those studies that seem to indicate a somewhat greater salience attributed to religion among those struggling with mental illness (Neeleman & Lewis, 1994). Among a sample of consecutively admitted psychiatric patients in the United Kingdom (N = 52), 22% reported that religion was the most important part of their lives, and 30% reported an increase in their religious faith after the onset of their illness (Kirov, Kemp, Kirov, & David, 1998). Consistent with other research on coping (Pargament, 1997), this effect seems most pronounced among those for whom spirituality is particularly important. Among the 11 clients for whom religion was the most important aspect of their lives, 64% reported an increase in their faith after their illness commenced (Kirov et al., 1998).

Spirituality and Recovery From Mental Illness

In addition to helping clients cope with the onset of mental illness, spirituality often functions as a significant source of strength that facilitates recovery (Fallot, 1998a). Fitchett et al.'s (1997) study of Midwestern inpatients (N = 51) found that 68% reported receiving "a great deal" of strength and comfort from their religion. Among a sample of spiritually interested clients with serious mental illness attending psychosocial rehabilitation centers in Maryland (N = 30), 83% felt their spiritual beliefs had a positive influence on their illness (Lindgren & Coursey, 1995).

In the United Kingdom, Kirov et al. (1998) examined the extent to which clients (N = 52) relied on their religion to deal with mental illness. Sixty-one percent of respondents used their religion to cope with unpleasant experiences, get better, or to stay mentally healthy. For example, clients reported that looking to God for assistance or knowing that He cared for them helped them to cope or recover from their mental illness.

Sullivan (1994, 1998) explored clients' perceptions of factors that contribute to recovery among a sample of Midwestern clients (N = 46) drawn from community mental health centers. To qualify for the study, individuals had to exhibit recovery from severe and persistent mental illness. In addition to factors such as medication, vocational activity, professional helpers, and support from family members, 46% of respondents indicated that spirituality was important to their success in achieving recovery.

Among a sample of consecutively admitted Canadian inpatients (N= 88), Baetz et al. (2002) found that higher levels of attendance at worship services was associated with lower levels of depression, lower levels of current and lifetime alcohol abuse, and higher levels of life satisfaction. In addition, increased levels of attendance at worship services, along with the use of religious thoughts and activities as important coping mechanisms, were also associated with the length of time spent in the psychiatric ward. In other words, the length of stay in the psychiatric ward was significantly shorter for clients who attended worship services or used religious thoughts and activities as the most important strategy to deal with their illness.

In what is perhaps the most methodologically rigorous study to date, Verghese et al. (1989) conducted a 2-year follow-up study on clients diagnosed with schizophrenia (N = 386) in India. At follow-up, 64% had experienced remission, with multivariate regression revealing that an increase in religion was associated with better outcomes. That is, an increase in religious activities was associated with a greater probability of remission.

Spirituality may be an especially important factor in recovery for disadvantaged populations, a significant concern for a profession charged with providing special attention to persons who are oppressed and disenfranchised (National Association of Social Workers, 1999). Among a United Kingdom sample of clients with mental illness (N = 52), women and non-Whites were more likely to be religious than men or Whites. This finding is consistent with research indicating that women, members of the working class, and various minority groups are more likely to report that spirituality plays an important role in their lives (N. J. Davis & Robinson, 1997; Gallup & Lindsay, 1999; Pargament, 1997).

Women and minority groups may also be more likely to use their spirituality to assist them in recovery from mental illness. On the basis of self-report, Kirov et al. (1998) sectioned their United Kingdom sample (N = 52) into two groups: (a) those who relied on religion to get better or to stay healthy and (b) those who did not rely on religion to get better or to stay healthy. Using logistic regression to control for confounding variables, these researchers found that women and non-Whites were more than twice as likely to rely on their religion than men or Whites. In short, women and minority groups struggling with mental illness were more likely to be religious, and they were also more likely to turn to their faith as a means of coping, getting better, and staying healthy (Kirov et al., 1998).

Spiritual Assessment

As the above material implies, spirituality is often central to clients' understanding of themselves and their external world. To provide culturally sensitive services, and to operationalize clients' spiritual strengths to help ameliorate or cope with problems, it is necessary to conduct a spiritual assessment to understand clients' spiritual worldviews (Fallot, 1998a; Plante & Sharma, 2001). As Plante and Sharma (2001) observed, the research suggests that to develop effective treatment plans for clients who are dealing with mental illness, it is necessary to consider the role of spirituality and religion.

As noted above, JCAHO (2002) recommends that a spiritual assessment be conducted and specifies that, at a minimum, the assessment should determine clients' important spiritual beliefs, significant spiritual practices, and denominational affiliation. The purpose of the initial assessment is twofold: to identify the effect of clients' spirituality on service provision, if any, and to determine whether a further, more extensive assessment is required.

Table 1 provides a brief, concise question set that is designed to elicit the information stipulated in the JCAHO (2002) requirements. As can be seen, the questions emphasize the functional nature of spirituality in clients' liveshow spirituality acts as a personal and environmental strength. Rather than focusing on the content of clients' spiritual worldviews, assessment should be aimed at determining how clients' spiritual beliefs and practices influence their functioning.

Depending on the responses to Questions 1 and 2, social workers may wish to break Question 3 into two discrete items for more specificity in terms of beliefs and practices (e.g., "Are there certain spiritual beliefs that are particularly helpful in dealing with problems?" Are there particular spiritual practices that you find especially useful when facing difficult circumstances?") In other words, if clients' replies suggest that spirituality is a significant factor in their personal ontology, exploring the belief and practice dimensions separately may yield more clinically useful information. Similarly, if previous responses warrant, it may also be helpful to ascertain how often clients engage in spiritual or religious practices and the salience of the practices to clients.

Question 6 explores clients' spiritual needs. In addition to asking about religious needs in a general, nonspecific sense, it may be helpful to list some common spiritual needs (e.g., "Are there any spiritual needs I can help you address such as arranging a visit from the chaplain or your pastor?"). When asked in a general, nonspecific manner (e.g., "Do you have any religious needs?"), Fitchett et al.'s (1997) study of the religious needs of psychiatric inpatients (N = 51) found that only 58% of respondents answered affirmatively. However, when asked whether they had any needs in eight specific areas, clients were much more likely to respond affirmatively to a number of the listed areas. A list of the eight areas surveyed along with the percentage of clients who responded affirmatively in each area appears in Table 2. In essence, Table 2 provides social workers with some idea of the needs clients may have in regard to spiritual beliefs, practices, and social support.

As noted above, the initial assessment may reveal that a further, more comprehensive spiritual assessment is warranted. For example, the initial assessment may indicate that spirituality is a particularly significant dimension in the client's life, with the potential to affect how treatment strategies are formed, developed, and implemented. In such contexts, social workers may wish to explore with the client the possibility of conducting a complete spiritual assessment to supplement the initial assessment.

When considering a complete spiritual assessment, it is vital that social workers have access to and employ useful assessment tools (Plante & Sharma, 2001). I have developed a complementary set of five assessment tools that highlight different aspects of clients' spiritual stories. Social workers might acquaint themselves with the respective strengths of each assessment method, as well as with alternative approaches developed by other authors, and choose the tool that most appropriately corresponds to the client's needs and interests. The purpose should be to avoid a one-size-fits-all approach to assessment and select an assessment tool that provides the best fit for each unique client-practitioner interface.

Much like traditional family histories, spiritual histories (Hodge, 2001a) offer a verbally based account of clients' spiritual sagas. Spiritual life maps (Hodge, in press-b) cover the same time span, but in a diagrammatic format that may appeal to more artistic, or less verbally oriented, clients. Spiritual genograms (Hodge, 2001b) chart the flow of spirituality over the course of at least three generations and may be particularly appropriate in situations in which the extended family plays a more central role, as is frequently the case with certain minority populations such as Hispanics. Spiritual ecomaps (Hodge, 2000; Hodge & Williams, 2002) depict the client's present, existential relationships with key spiritual variables in their environment and, consequently, maybe useful for more present-focused clients who are interested in exploring current spiritual strengths rather than historical influences. Ecograms (Hodge, in press-a) incorporate the strengths of traditional genograms and ecomaps, allowing practitioners to examine the interconnections between historical influences and present relationships in a single pictorial instrument. Although all the approaches can be used with families, perhaps spiritual genograms, ecomaps, and ecograms are best suited for family therapy.

Spiritual Competency

When conducting a spiritual assessment, social workers are ethically mandated to exhibit spiritual competency (National Association of Social Workers, 1999, 1.05). Spiritual competency can be understood as a more specific form of cultural competency (Boyle & Springer, 2001). Spiritual competency is composed of three components: (a) knowledge of one's own spiritual worldview and associated biases; (b) an empathic understanding of the client's spiritual worldview; and (c) the ability to develop intervention strategies that are appropriate, relevant, and sensitive to the client's spiritual worldview (Sue, Arredondo, & McDavis, 1992).

Spiritual competency can be envisioned as a continuum ranging from spiritually destructive practice on one end to spiritually competent practice on the other end (Manoleas, 1994). It is often helpful to understand that developing spiritual competency is a lifelong process-no one has fully arrived. It is also important to realize that practitioners are commonly at different places along the continuum with different spiritual groups. For example, a social worker may be relatively more competent working with clients from liberal Protestant traditions than with clients from Islamic traditions.

The importance of spiritual sensitivity may be particularly salient when working with spiritual populations that are underrepresented in social work circles, such as evangelical Christians (Hutchison, 1999; Sheridan, Wilmer, & Atcheson, 1994) and Muslims (Canda & Furman, 1999; Smith, 1999). Because social workers have received little training about nondominant spiritual worldviews from educators who are themselves adherents of these worldviews (Canda & Furman, 1999), they are unlikely to be familiar with the cultural norms among these populations.

The extant data emphasizes the importance of developing spiritual competency when working with clients from minority spiritual traditions. A study of Midwestern evangelical Christians (N = 76) found that 83% felt social workers did not understand their spiritual beliefs and values, and, consequently, these Christians were very hesitant to receive services from social workers (Furman, Perry, & Goldale, 1996). Adherents of many other subordinate faith traditions may share similar concerns (Richards & Bergin, 2000; Sims, 1999). Among a sample of clients with serious mental illness who exhibited an interest in spirituality (N= 30), 34% reported that they would be uncomfortable discussing spirituality with their therapist, whereas an additional 17% indicated they would feel "somewhat comfortable" discussing spirituality (Lindgren & Coursey, 1995). In other words, more than 50% of respondents for whom spirituality was a salient factor in their lives exhibited some degree of hesitation about discussing spirituality with their therapist.

Whereas developing an empathetic sensitivity to a given spiritual culture is an ongoing process, a number of principles exist that can generally be applied across spiritual traditions. First, it is critical to demonstrate respect for clients' spiritual autonomy (Sims, 1999). Social workers should exhibit respect for clients' spiritual beliefs, values, and practices. This includes affirming the right of clients to refrain from discussing spirituality, a stance that many individuals with mental illness prefer to adopt. For instance, among clients interested in spirituality (N = 30), 37% of respondents indicated they would like to refrain from discussing spirituality in therapy (Lindgren & Coursey, 1995).

One practical way to exhibit respect for a client's spiritual worldview is to adopt and use language drawn from that worldview. It is often initially helpful to use common terms that resonate with a wide number of clients (e.g., "I was wondering if you attend a church") along with a broader term to which others can relate (e.g., "or some other type of spiritual community"). However, as soon as a client shares a term that reflects his or her worldview (e.g., synagogue), then that term should be incorporated into the dialogue as soon as possible.

Second, it is appropriate to assume the posture of a cultural anthropologist (Patterson, Hayworth, Turner, & Raskin, 2000). Ideally, social workers should demonstrate curiosity and interest as they seek to allow clients to guide them toward a fuller understanding of their worldviews. The goal is to create an environment in which clients feel safe enough to share the sacred dimension of their being.

Third, it is helpful to exhibit sensitivity to the biases people of faith often encounter in the larger secular culture (Roberts, 1999). Demonstrating awareness of, for example, the discrimination evangelical Christians (Gartner, 1986; Skill & Robinson, 1994), Muslims (Stockton, 1994), and other devout theists frequently experience can build bridges between clients and social workers.

Fourth, it is important to monitor religious countertransference (Genia, 2000; Hodge, 2003). Social workers who have rejected their family of origin's faith may be particularly susceptible to experiencing religious countertransference biases when encountering individuals from these faiths. For example, a social worker raised in a devout Christian home who has since abandoned his or her former faith may attempt to work through unresolved issues when encountering clients from Christian traditions instead of attending to the client's needs (Sims, 1999).

These four principles can be seen as building blocks in that they lay a foundation for spiritually competent practice. The larger goal is to move through the following four-step process: to develop self-awareness of the lens used to view prominent faith-based cultures, to learn how the biases associated with one's own lens affects one's understanding of particular faith groups, to learn to set aside the lens and associated biases and see reality through the worldview used by the faith group, and come to the point of appreciating reality as seen through the eyes of the client's worldview.

Discerning "Normal" Spirituality

A critical aspect of spiritual competency is discerning "normal" or "healthy" spirituality. In some cases, psychosis is manifested in forms that reflect spiritual content (e.g., a client who believes that he is Jesus). Indeed, many mental health professionals remain concerned about formally incorporating spirituality into assessment and intervention because of fears that doing so will worsen symptoms and decrease the client's willingness to follow treatment recommendations (Fallot, 2001b).

As Fallot (2001a) noted, however, little ground exists for mental health professionals to single out spirituality as an area of unique concern. Empirical evidence suggests that the content of hallucinations is often derived from clients' cultures. In a study in the United Kingdom and Saudi Arabia that explored the characteristics and content of hallucinations (N = 75), no significant differences emerged in loudness, frequency, distress caused, difficulty in ignoring the voices, source, validity, and perceived reality of the hallucinations (Kent & Wahass, 1996). However, in terms of the content, in Saudi Arabia, a more religious nation relative to the largely secular United Kingdom, respondents reported significantly more religious themes.

In the United States, between 10% and 54% of psychotic disorders are accompanied by what is commonly seen as abnormal spiritual content (e.g., believing one's roommate is the devil) and/or unhealthy preoccupations (e.g., believing one has committed the unpardonable sin; Koenig, et al., 2001). Concurrently, the Diagnostic and Statistical Manual of Mental Disorders, 4th edition-text revision (DSM-IV-TR; American Psychiatric Association, 2000) acknowledges that in some spiritual cultures, experiencing what appears to be an auditory hallucination with spiritual content is normative (e.g., seeing the Virgin Mary or hearing God's voice). In other words, spiritual content that is perceived by the dominant secular culture to be abnormal or unhealthy is often viewed as a normal expression of spirituality when understood from within the context of many non-traditional spiritual worldviews.

The DSM-IV-TR (American Psychiatric Association, 2000) provides guidelines for distinguishing between content that reflects psychosis and content that is normative in the area of spirituality (e.g., a client who reports that he or she hears God's voice). First, note the client's spiritual identity and associated worldview (e.g., Pentecostal, which is open to metaphysical phenomena). Second, understand to what extent the client's manifestation is normative within the context of the client's spiritual worldview (e.g., within the context of a Pentecostal worldview, hearing God's voice is a normal occurrence and therefore not necessarily a manifestation of psychosis). It is also important to emphasize that even if the metaphysical experience reported by the client appears to be abnormal within the context of their worldview, the experience should be assessed in light of the person's overall functioning (Fallot, 2001b).

It is not always clear, however, exactly what constitutes normative spiritual experiences within the client's spiritual worldview. In cases in which doubt exists, social workers should seek out collaborations with clergy (Gilbert, 2000). In addition to providing individual services that address clients' needs, and linking clients to social support resources in their spiritual communities, clergy are typically able to provide information about what are considered appropriate expressions of spirituality in a given spiritual tradition.

It is important to emphasize that clergy from the client's specific tradition should be consulted. For instance, it is inappropriate to collaborate with a mainline Protestant pastor when seeking advice about the spiritual content related by a client who is a member of a Pentecostal denomination. Although both may be Protestants, mainline Christians and Pentecostal Christians tend to operate from differing epistemologies, which engender different understandings of what constitutes normative spiritual values and beliefs (Hunter, 1991). If, for some reason, it is impossible to collaborate with clergy from the client's own religious community, then social workers should strive to ensure that the match between the client's worldview and the clergy's worldview is theologically compatible. As in other matters, it is often clients themselves who are the best source of information about appropriate candidates for collaboration.

Spiritual Interventions

Although psychosis can be manifested in spiritual content, it is important to reiterate that spirituality is positively associated with mental health. Furthermore, as noted in the introductory sections, spirituality is often a key component in recovery from mental illness. Social workers can facilitate the recovery process by helping clients operationalize their spiritual strengths.

Conducting an assessment, particularly a complete spiritual assessment, is likely to uncover strengths and resources that can be tapped to foster recovery. Depending on the needs and desires of clients, a number of possible interventions exist from which social workers can draw. Reviewed directly below are those interventions that research suggests clients with mental illness may find useful.

Social workers can assist clients by accenting positive, recovery-oriented narratives drawn from clients' spiritual worldviews (Fallot, 1998b). As constructivist theorists have observed, our personal narratives provide a framework for understanding ourselves and the world around us. Helping clients focus on their capabilities, strengths, resilience, and resources can help them overcome problems by fostering the adoption of new self-perceptions that, in turn, enable clients to address their problems more effectively. Common themes that exist in many spiritual worldviews that have been helpful in coping and recovering from mental illness include a sense of identity as a spiritual person, hope for the future, the experience of being in a loving relationship with God, and a view of life as a journey in which one has personal responsibility.

Linking clients with churches and other faith communities can be an effective intervention (Shifrin, 1998). As the results depicted in Table 2 suggest, many people with mental illness live with loneliness and isolation and, consequently, have significant social needs. In many situations, congregations can provide a haven of support through which these needs are addressed (Sullivan, 1998).

Spiritual practices such as scripture reading, prayer, meditation, listening to worship music, and spiritual rituals are often important factors in fostering recovery from mental illness (Carson & Huss, 1979; Fallot, 1998b). Reading the Bible, for example, can function as a reminder for clients of God's concern for the marginalized and disenfranchised members of society and provide hope and optimism about the future. As a counter to the disorganization that often accompanies mental illness, spiritual rituals, such as praying at regular times, listening to music, taking the sacraments, and so forth can help foster a sense of structure and organization.

Although the importance of spiritual practices is widely affirmed by many clients with mental illness (Kroll & Sheehan, 1989; Lindgren & Coursey, 1995; Neeleman & Lewis, 1994), clients may engage in these practices unsystematically (Wahass & Kent, 1997). In many cases, the secular atmosphere of many hospitals and treatment centers may function to discourage clients from engaging in important practices. Social workers can often act as brokers between the hospital and the client, by, for example, arranging a place for Muslim clients to practice the five daily prayers prescribed by Islam.

A number of clinical trials have demonstrated the effectiveness of spiritually modified cognitive-behavioral therapy. With this approach, traditional cognitive-behavioral approaches are modified with tenets derived from the client's spiritual belief system. With Muslims, for example, cognitive-behavioral therapy modified with beliefs drawn from the Koran have been found to be at least as effective as traditional forms of therapy for anxiety disorders (Azhar, Varma, & Dharap, 1994), bereavement (Azhar & Varma, 1995a), and depression (Azhar & Varma, 1995b), while ameliorating problems at a faster rate in all three studies. Similarly, positive outcomes have been found when treating depression among Christians (Hawkins, Tan, & Turk, 1999; Propst, 1996) and perfectionism among Mormons (Richards, Owen, & Stein, 1993). Readers interested in further information regarding this method may wish to consult the work of Ellis (2000), for traditional cognitive interventions that have been modified with theistic tenets, and Backus (1985), for interventions that have been modified with Christian beliefs.

Wahass and Kent (1997) examined the effectiveness of spiritually modified psychological interventions designed to alter the characteristics and content of common symptoms of schizophrenia. The sample consisted of three Muslim clients in Saudi Arabia who were experiencing persistent auditory hallucinations despite the administration of antipsychotic medications. Although 1 client was reluctant to engage with the therapist, the other 2 clients benefited significantly from the interventions, reporting reductions in the frequency, loudness, and hostility of the voices, in conjunction with a heightened ability to disbelieve and ignore the voices. Lower levels of distress, anxiety, and depression were reported at the end of therapy.

When conducting an assessment, particularly a complete assessment, it may be helpful to be aware of these interventions. Social workers can explore clients' spiritual strengths as they intersect the interventions delineated above during the assessment process. For example, armed with the knowledge that spiritual beliefs can engender a therapeutically beneficial sense of hope, practitioners might attempt to identify spiritual beliefs that foster hope during the assessment.

Conclusion

For people with mental illness, life is difficult. Internal voices, intense stimuli, out-of-control thoughts, confusing ideas, profound fears, and other symptoms can make life almost unbearable. For individuals with schizophrenia, for instance, the cognitive process often becomes so disorganized that even communicating can become a stressful endeavor. Various connections between ideas and concepts that most people would normally screen out as unimportant fight to redirect one's thoughts in often incompatible directions. Benioff (1995) offered one person's account of a process-holding a simple conversation with another person-that most of us take for granted:

I start thinking or talking about something, but I never get there. Instead I wander off in the wrong direction and get caught up with all sorts of different things that may be connected with the things I want to say but in a way I can't explain. People listening to me get more lost than I do. (pp. 90-91)

The inability to communicate and interact with the surrounding world often leads to a deep sense of isolation, loneliness, and ultimately, despair. Feelings of isolation are often compounded by a materialistic society that frequently stigmatizes and excludes people with mental illness. It is illustrative that a person with schizophrenia is frequently called a schizophrenic, whereas a person with cancer is never called a cancerite. Subsuming the person under the illness sends the message that their illness sets them apart from other members of society. The process of being hospitalized, which is often involuntary, can accentuate feelings of isolation, shame, and loss of control.

In light of the internal and external pressures that people with mental illness encounter, it is critical that social workers demonstrate compassion when interacting with this population (Nelson, 1997; Sullivan, 1998). Communicating acceptance and understanding of the hardships people with mental illness encounter on a daily basis is often therapeutic. Employing empathetic listening skills while seeking to understand the sources of strength that foster the courage to carry on in the face of adversity can help social workers reinforce positive narratives.

For people who are feeling misunderstood and isolated, the belief that God has not abandoned them can be an important source of strength. Knowing that God has a plan for one's life, that hardships are temporary, and a future hope exists can engender the courage to face the day. Worshipping with other believers can alleviate loneliness and provide a sense of coherence to life. Consequently, whereas the larger society often views clients' mental illness as their core identity, for many clients it is their spirituality that provides their core identity (Fallot, 1998b). It is this human reality that highlights the importance of training in the area of spiritually competent assessment.

In addition, the recent JCAHO (2002) stipulations imply the need for training to be able to implement the recommendations in a professional manner. Educational programs might consider broadening their scope to incorporate material on spiritual assessment and competency in their extant discussion of cultural competency. Practice material might be developed to assist social workers in forming collaborations with clergy. In addition, research could explore the ways in which practitioners might use clients' spiritual strengths to cope and recover from mental illness. Although spirituality is the most important asset for many people with mental illness, much work remains to be done to assist clients in operationalizing this vital resource.

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David R. Hodge, PhD, is a postdoctoral fellow with the Program for Research on Religion and Urban Civil Society, University of Pennsylvania, Leadership Hall, 3814 Walnut Street, Philadelphia, PA 19104. He has written extensively on spirituality and religion and conducted the first national studies of social work students' perceptions of spiritual sensitivity.

Manuscript received: August 29, 2002

Revised: September 12, 2003

Accepted: September 25, 2003

Copyright Families in Society Jan-Mar 2004
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