Spiritual assessment and native Americans: establishing the social validity of a complementary set of assessment tools.
Abstract: Although social work practitioners are increasingly likely to administer spiritual assessments with Native American clients, few qualitative assessment instruments have been validated with this population. This mixed-method study validates a complementary set of spiritual assessment instruments. Drawing on the social validity literature, a sample of experts in Native culture (N = 50) evaluated the instruments' cultural consistency, strengths, limitations, and areas needing improvement. Regarding the degree of congruence with Native American culture, verbally based spiritual histories ranked highest and diagrammatically oriented spiritual genograms ranked lowest, although all instruments demonstrated at least moderate levels of consistency with Native culture. The results also suggest that practitioners' level of spiritual competence plays a crucial role in ensuring the instruments are operationalized in a culturally appropriate manner.

KEY WORDS: American Indians; Native Americans; religion; spiritual assessment; spirituality
Article Type: Report
Subject: Native Americans (Religious aspects)
Native Americans (Social aspects)
Social values (Religious aspects)
Authors: Hodge, David R.
Limb, Gordon E.
Pub Date: 07/01/2011
Publication: Name: Social Work Publisher: National Association of Social Workers Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2011 National Association of Social Workers ISSN: 0037-8046
Issue: Date: July, 2011 Source Volume: 56 Source Issue: 3
Topic: Event Code: 290 Public affairs
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 262582572
Full Text: 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:

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:

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.

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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.
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?


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.


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.
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