A template for spiritual assessment: a review of the JCAHO requirements and guidelines for implementation.
Abstract: Growing consensus exists regarding the importance of spiritual assessment. For instance, the largest health care accrediting body in the United States, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), now requires the administration of a spiritual assessment. Although most practitioners endorse the concept of spiritual assessment, studies suggest that social workers have received little training in spiritual assessment. To address this gap, the current article reviews the JCAHO requirements for conducting a spiritual assessment and provides practitioners with guidelines for its proper implementation. In addition to helping equip practitioners in JCAHO-accredited settings who may be required to perform such an assessment, the spiritual assessment template profiled in this article may also be of use to practitioners in other settings.

KEY WORDS: assessment; cultural competency; JCAHO; religion; spirituality
Subject: Spirituality (Analysis)
Social case work (Standards)
Social workers (Religious aspects)
Author: Hodge, David R.
Pub Date: 10/01/2006
Publication: Name: Social Work Publisher: National Association of Social Workers Audience: Academic Format: Magazine/Journal Subject: Sociology and social work Copyright: COPYRIGHT 2006 National Association of Social Workers ISSN: 0037-8046
Issue: Date: Oct, 2006 Source Volume: 51 Source Issue: 4
Topic: Event Code: 350 Product standards, safety, & recalls; 290 Public affairs
Organization: Organization: Joint Commission on Accreditation of Healthcare Organizations
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 155869768
Full Text: Growing consensus exists that spiritual assessment is an important aspect of holistic service provision (Gilbert, 2000). Studies have repeatedly found that most practitioners affirm the importance of spiritual assessment (Canda & Furman, 1999; Carlson, Kirkpatrick, Hecker, & Killmer, 2002; Prest, Russel, & D'Souza, 1999; Sheridan & Amato-von Hemert, 1999). For instance, among a national sample of National Association of Social Workers (NASW) members engaged in direct practice (N = 2,069), approximately 60 percent agreed that an exploration of spirituality and religion should be part of the intake or assessment process (Canda & Furman).

Furthermore, social workers are increasingly being called on to conduct spiritual assessments. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2004a) is the largest and most influential health care accrediting body in the United States. In keeping with the large number of social workers employed in JCAHO-accredited settings, NASW (2004) maintains an ongoing partnership with JCAHO. In addition to accrediting most of the nation's hospitals, JCAHO also accredits thousands of other organizations and programs providing health and mental health services.

In 2001, JCAHO revised its accreditation standards to require the administration of a spiritual assessment. Spiritual assessments are now mandated in a number of settings, including hospitals, home care organizations, long-term care facilities, and certain behavioral health care organizations such as those providing addiction services.

Although the importance of spiritual assessment is increasingly acknowledged, it remains an open question how well equipped social workers are to administer such assessments. Research indicates that most practitioners have received little, if any, training on spirituality and religion during their graduate training (Canda & Furman, 1999; Carlson et al., 2002; Furman, Benson, Grimwood, & Canda, 2004; Heyman, Buchanan, Musgrave, & Menz, in press; Murdock, 2004). Consistent with this lack of training, Canda and Furman found that only 17 percent of NASW-affiliated direct practitioners felt that social workers generally possessed the knowledge to address spiritual issues.

In light of the paucity of training, it is perhaps unsurprising that many practitioners desire to learn more about spiritual assessment (Derezotes, 1995). For example, among a random sample of clinical members of the American Association for Marriage and Family Therapy (N = 153), 54 percent indicated that they wanted to learn more about integrating spirituality into assessment and interventions (Carlson et al., 2002). Similarly, the professional literature features many voices articulating the need for more material to help equip practitioners to work with clients' spirituality and religion (Ai, 2002; Belcher & Cascio, 2001; Brenner & Homonoff, 2004; Gilbert, 2000; Sahlein, 2002).

In this article, I address the need for additional material on spiritual assessment by reviewing JCAHO's spiritual assessment requirements and developing guidelines that may be useful in the administration of an assessment. It may be helpful at this juncture to note that the use of the JCAHO requirements as a template does not preclude application of the material in other, non-JCAHO-accredited settings. This template is not so much a distinctive assessment tool or instrument as it is a broad framework for thinking about spiritual assessment. Because it was developed to enhance service provision to clients, it is likely to be of interest to a broad cross-section of social workers interested in spiritual assessment and cultural competence, regardless of whether the practitioner is employed in a JCAHO-accredited setting.

It is also important to note that other approaches to spiritual assessment exist. For instance, a wide array of quantitative scales has been developed. Readers interested in these options may wish to consult Hill and Hood's (1999) review. Although a discussion of these approaches is beyond this article's scope, they represent important contributions to the literature, and social workers may find them useful in many settings. Owing to the clinical utility of qualitative assessments and the influence of the JCAHO requirements, this article's focus is the JCAHO assessment template.

DEFINITIONS OF SPIRITUALITY, RELIGION, AND SPIRITUAL ASSESSMENT

Although various conceptualizations of spirituality and religion exist, they are generally seen as interconnected but distinguishable constructs (Canda & Furman, 1999; Carroll, 1998; Hodge, 2001 ; Miller & Thoresen, 2003). Consistent with this understanding, spirituality can be viewed as an ontologically driven impulse toward union or relationship with God (or ultimate transcendent reality), whereas religion can be understood as an expression of the spiritual relationship that unites an individual with a moral community that shares similar experiences of transcendent reality (Hodge, 2001; Joseph, 1988; Stanard, Sandhu, & Painter, 2000).

Assessment can be understood as the process of gathering information into a concise picture that provides the basis for action decisions (Hepworth, Rooney, & Larsen, 2002; Rauch, 1993). Although there is debate over whether spirituality or religion is the broader construct (Hill & Pargament, 2003; Sahlein, 2002), in this article, consistent with JCAHO's (2001) understanding of the two constructs, I view spirituality as the broader construct. Thus, conducting a spiritual assessment entails an examination of both spiritual and religious dimensions. Spiritual assessment can be thought of as the process of gathering, analyzing, and synthesizing spiritual and religious information into a specific framework that provides the basis for, and gives direction to, subsequent practice decisions.

JCAHO SPIRITUAL ASSESSMENT REQUIREMENTS

As indicated earlier, JCAHO (2001) stipulates that practitioners conduct an initial, brief spiritual assessment with clients in many settings, including hospitals and behavioral health organizations providing addiction services. The same framework, however, is used in all settings. At a minimum, the brief assessment should include an exploration of three areas: (1) denomination or faith tradition, (2) significant spiritual beliefs, and (3) important spiritual practices.

JCAHO provides a list of questions to help operationalize the assessment (Table 1). It is important to note that JCAHO does not require the use of all, or even any, of these questions. Rather, the apparent intent is to give practitioners, who may not be used to addressing spirituality and religion in practice settings, some kind of sense of the type of questions that might be relevant in the course of conducting a spiritual assessment. Put differently, the questions underscore the type of content areas that might be explored during a spiritual assessment.

If a decision is made to draw on the JCAHO questions, then consideration should be given as to how the questions are phrased. For instance, simply asking for the name of clients' clergy (question 6) implies that clients have a clergy person, which is unlikely to be the case for all clients. Ideally, questions should be phrased in a neutral manner that allows clients the freedom to respond in diverse ways. For instance, practitioners might begin an assessment by asking, "I was wondering if spirituality or religion is important to you?" or perhaps "I was wondering if you consider spirituality or religion to be a personal strength?" This type of phrasing gives clients the freedom to respond negatively or affirmatively, validating the experiences of those who are spiritual, religious, both, or neither.

Similarly, asking about the role of churches or synagogues (question 10) leaves out temples, mosques, and other forums in which spirituality is expressed. Practitioners may wish to frame questions using a common term that has wide cultural resonance (for example, "church"), so that clients understand the entity being discussed, and then follow the term with an inclusive term (for example, "spiritual community") that captures a wide array of experiences (Hodge, 2004). Thus, practitioners might ask, "I was also wondering if you attend a church or some other type of spiritual community?" If the client attends a mosque, for example, then that term would be used in all subsequent conversation.

Table 2 provides one possible set of questions that might be used to meet the JCAHO recommendations. Depending on how clients answer question 1, practitioners may wish to break question 2 into two separate items, one that explores beliefs and another that explores practices. Similarly, depending on the responses, it may also be helpful to explore how often clients engage in spiritual or religious practices or attend religious services, as well as some of the content areas suggested by the JCAHO questions (Table 1). All questions, however, should be guided by the rationales that underlie the brief assessment.

Rationales Underlying Brief Assessment

The purpose of the brief assessment is twofold (JCAHO, 2001). One of the rationales is to determine the effect of the client's spirituality on service provision. As the NASW Standards for Cultural Competence in Social Work Practice (NASW, 2001) implies, clients' spiritual beliefs inform an array of areas of significance to social workers. Unique, spiritually informed worldviews and cultures are often formed on the basis of similar or shared experiences of transcendent reality (Koenig, 1998; Richards & Bergin, 2000; Van Hook, Hugen, & Aguilar, 2001). Consequently, spiritual beliefs and practices often have to be taken into account to ensure that service provision is as effective and culturally sensitive as possible.

Clients' spiritual beliefs and practices can function as both barriers and assets to service provision. For example, regarding the former, clients' spiritual beliefs may preclude them from affiliating with certain types of therapeutic groups (JCAHO, 2003). More specifically, some Muslims may be hesitant to join groups that are composed of members of the opposite sex (Smith, 1999). In terms of assets, an assessment can help provide information that can be used to match the client's needs with appropriate settings and interventions. Individuals wrestling with schizophrenia, for example, may be aided in their recovery from mental illnesses by active participation in a church fellowship (Sullivan, 1997).

The second rationale for conducting an initial brief assessment is to identify whether a further, more comprehensive spiritual assessment is needed (JCAHO, 2001). As the JCAHO requirements acknowledge, for some clients spirituality is not a salient life dimension. Many people are unaffiliated with a faith tradition and their lives are uninformed by any significant spiritual beliefs or practices. In other cases, spirituality and religion play a marginal role or are peripheral to service provision. In such instances, a brief assessment may be all that is required.

Yet, in numerous other instances, a brief assessment may suggest that a comprehensive assessment is warranted. JCAHO, however, provides no guidelines for determining whether practitioners should proceed from a brief assessment to a comprehensive spiritual assessment. Accordingly, practitioners may wish to consider the following principles in contemplating whether a comprehensive assessment is an appropriate option in a particular client--practitioner interface.

Guidelines for Moving to a Comprehensive Assessment

At least four somewhat interrelated factors may bear on the decision to move from a brief to a comprehensive assessment. It should be noted at the outset that these four guidelines are often held in tension with, and inform, one another. In brief, these four principles can be summarized as respect for client self-determination, the practitioner's ability to provide culturally competent services, the degree to which the norms of the client's faith tradition relate to service provision, and salience of spirituality in the client's life.

Client Autonomy. One important factor that should be weighed is the ethical principle of self-determination enumerated in the NASW Code of Ethics (NASW, 2000). Respect for client autonomy is a central overarching social work value that informs essentially all social work practice, including practice related to spirituality and religion (Cascio, 1998; Sahlein, 2002). For instance, Canda, Nakashima, and Furman (2004) take client autonomy in the area of spirituality so seriously that they recommend that practitioners generally refrain from praying silently for clients unless they have obtained the client's permission to engage in unspoken prayer on their behalf.

Similarly, it is important to obtain clients' consent before proceeding with a spiritual assessment. Although many clients may be willing to answer the relatively few questions involved in a brief assessment, informed consent should be obtained again before proceeding with a comprehensive assessment. Indeed, it is perhaps best to view informed consent as an ongoing process in which practitioners continuously monitor clients' responses to ensure that they remain fully supportive of the continuing dialogue.

It is important to be aware of the reality that for many clients spirituality represents a private, sacred dimension of their personal ontology. Some devout clients may be hesitant to trust social workers with such a personal dimension of their being (Furman, Perry, & Goldade, 1996; Richards & Bergin, 2000), which is understandable in light of the paucity of training on spirituality and religion most social workers have received (Canda & Furman, 1999; Furman et al., 2004; Murdock, 2004; Sheridan & Amato-von Hemert, 1999). Consequently, in keeping with the profession's ethical standards, social workers must respect clients' desires to keep this dimension of their being confidential if they so desire.

Concurrently, if clients desire to integrate their spiritual beliefs and practices into service provision, then practitioners should attempt to respect this decision as well. Indeed, studies suggest that most clients and potential clients want to have their spiritual beliefs and values incorporated into the therapeutic dialogue (Bart, 1998; Larimore, Parker, & Crowther, 2002; Mathai & North, 2(303; Rose, Westefeld, & Ansley, 2001).

Incorporating clients' beliefs and practices into the dialogue not only reflects a commitment to the profession's ethical values, but it is also likely to enhance client cooperation and participation in service provision (Hepworth et al., 2002). Clients are more likely to become, and remain, engaged in the service provision process if their values and beliefs are respected and included in decision making in meaningful ways. Consequently, if clients desire to incorporate their spiritual beliefs and values into service provision, the enhanced client buy-in should be factored into the decision to administer a comprehensive assessment.

Cultural Competence. A second factor to consider is the degree to which practitioners are equipped to work with the client's specific spiritual and religious values in a culturally sensitive manner (Yarhouse & VanOrman, 1999). The NASW Standards for Cultural Competence in Social Work Practice (NASW, 2001) states that social workers should be able to respond respectfully and effectively with people of all religious backgrounds. Cultural competence with religious people entails recognizing, affirming, and valuing their beliefs and values in a manner that protects and preserves each client's dignity. Stated conversely, social workers should attempt to ensure that they are sufficiently equipped, both professionally and personally, to avoid harming clients in the process of service provision.

The potential for harm to occur may be accentuated when the practitioner and client hold different spiritual beliefs or are members of different cultural groups. Social work, like other human projects, is a value-animated enterprise (Sermabeikian, 1994). As Gotterer (2001) noted, social workers have an array of value assumptions regarding how clinical work is best conducted, the appropriate questions to ask, the manner in which problems are defined, the issues that are considered problems, and how problems should be resolved. Consistent with Armstrong's (2000) observation, studies have suggested that social workers disproportionately affirm individually constructed worldviews, both spiritual and material, that are informed by secularist Enlightenment norms and values (Hodge, 2002; Shafranske, 2001; Sheridan, Wihner, & Atcheson, 1994).

Consequently, conflicts may occur between the more secular values affirmed by many social workers and the more traditional spiritual values affirmed by many clients, with the potential for harm being particularly pronounced when interacting with unfamiliar or underrepresented faith groups, such as Hindus, evangelical Christians, or Latter-Day Saints (Gotterer, 2001). As Reddy and Hanna (1998) noted regarding practice with Hindus, the use of typical Western secular values and related interventions may accentuate, rather then ameliorate, problematic functioning.

In addition to obtaining the necessary knowledge and skills needed to work with culturally different groups, it is also important to work through any personal issues that may tend to affect the interpersonal dyad. For example, "religious counter-transference" may be an issue when working with individuals from culturally different groups (Genia, 2000; Hodge, 2003a). As practitioners come face to face with values they have rejected in their personal lives, they may consciously or unconsciously react to these values in the clinical dialogue.

In short, if an initial assessment indicates the presence of a culturally different worldview that the practitioner may have difficulty working with in a culturally sensitive manner, then it may be advisable to refrain from conducting a comprehensive assessment. Furthermore, social workers should probably not work with such clients at all if they risk engaging in culturally insensitive practice. Consequently, serious consideration should be given to referring the client to another practitioner who has the necessary skills and knowledge to work with the particular client population in a culturally competent manner.

Spiritual Norms and Service Provision. Another factor that should be considered is the degree to which the norms of the client's faith tradition relate to service provision. In other words, if initial assessment reveals that the client's beliefs and practices may intersect with the provision of services, then conducting a comprehensive assessment may be warranted.

As stated earlier, clients' spiritual worldviews can affect attitudes and practices in a number of areas of significance to social workers, including views on child care, communication norms, diet, family relations, gender interactions, marital relations, medical care, recreation, schooling, and understandings of metaphysical reality (Pellebon & Anderson, 1999; Rey, 1997). In many instances, norms in these and other areas directly intersect service provision in the form of barriers and assets, as well as other intersections.

Consider, for instance, the case of a Pentecostal Christian facing a possible diagnosis of mental illness who reports hearing God's voice on a regular basis. Although hearing voices external to oneself is considered a marker for mental illness, the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) (American Psychiatric Association, 2000) acknowledges that it is normative in some spiritual cultures to experience what appears, from within the parameters of a secular worldview, to be auditory hallucinations. In other words, hearing an external voice is not necessarily a manifestation of mental illness with Pentecostal Christians because hearing God's voice is considered normative within the Pentecostal tradition (Dobbins, 2000; Gotterer, 2001). In such cases, a comprehensive assessment is necessary to determine whether the voice represents a manifestation of mental illness or is a client strength.

During the initial assessment, practitioners should be alert to various indicators that might suggest a connection between the client's spirituality and possible diagnoses, interventions, or other aspects of service provision. Making such connections typically requires some degree of cultural competence or, more specifically, some degree of knowledge regarding common norms extant in various denominations and faith traditions. If practitioners are aware of the fact that intimate cross-gender rater-actions are problematic for many Muslims, for example, they are more likely to explore the suitability of a Muslim client's participation in a mixed-gender group (Hodge, 2005b).

It is important not to stereotype or to assume that all people who self-identify as members of a particular faith tradition affirm certain beliefs and practices. Rather, the awareness of widely affirmed norms functions as a malleable, working framework, alerting practitioners to the need to explore the presence, if any, of a particular spiritual value in a client's life. If the initial assessment suggests the existence of certain spiritual beliefs and practices that may relate to later treatment decisions, then further assessment is warranted to clarify the exact nature of the relationship between the value in question and possible treatment decisions.

Spiritual Salience. Finally, a comprehensive assessment might be considered when spirituality plays a central role in the client's life. Spiritual salience varies significantly. Spirituality tends to play a larger role in the lives of marginalized groups, such as African Americans, women, and people who are poor, with the level of spiritual salience varying from person to person within these, as well as other, populations (Pargament, 2002).

If clients are highly spiritually committed, then the potential for conflicts to occur between the client's belief system and service provision is likely enhanced. In contrast with less devout individuals, who may be at ease with secular protocols, the norms in a given faith tradition are often more important to spiritually committed individuals (Richards & Bergin, 2000). A highly committed Muslim, for instance, may be more uncomfortable receiving services, particularly those that address intimate issues, from providers of the opposite sex than a less committed adherent of Islam (Smith, 1999).

Conversely, spiritual salience may also have a significant effect on operationalizing spiritual and religious assets. As noted earlier, many clients are interested in incorporating their spiritual values into service provision. More committed clients may be more likely to draw on their spiritual beliefs and practices to help them cope with or ameliorate problems (Pargament, 1997). In addition, practitioners may be able to explicitly incorporate clients' beliefs and practices into service provision by, for example, replacing the tenets of secular cognitive-behavioral therapy with tenets drawn from clients' spiritual belief systems (Ellis, 2000). Clients who are highly committed to their spiritual belief system may be more inclined to implement spiritually oriented interventions that resonate with their value system than more traditional secular interventions that have fewer contact points (Hepworth et al., 2002).

A significant and growing body of research indicates that a link exists between spirituality and religion and various mental and physical health outcomes (Koenig, McCullough, & Larson, 2001; Mahoney, Pargament, Tarakeshwar, & Swank, 2001; Pargament, 1997). Consistent with these findings, several studies attest to the effectiveness of integrating clients' spiritual beliefs and practices into treatment (Hodge, 2006). These studies have typically been conducted using relatively devout or committed individuals.

More specifically, Taoistically modified therapy has been used to address neurosis among adherents of Taoism (Xiao, Young, & Zhang, 1998). Therapy modified with tenets drawn from Islam has been used with Muslims to address anxiety disorder, bereavement, depression (Azhar & Varma, 2000), and schizophrenia (Wahass & Kent, 1997). Similarly, spiritually informed approaches have been used to deal with perfectionism among Latter-Day Saints (Richards, Owen, & Stein, 1993), as well as with obsessive compulsiveness (Gangdev, 1998) and depression among Christians (Johnson, Ridley, Devries, Pettorini, & Peterson, 1994; Propst, 1996). Finally, a non-tradition-specific, spiritually modified intervention has been used to address stress management among a religiously heterogeneous sample (Nohr, 2000).

Various degrees of methodological rigor are apparent in these studies, and further research is required to say anything definitive (Hodge, 2006). With these caveats in mind, the results do suggest that using spiritually informed interventions with spiritually committed clients yields outcomes that are equal or superior to the outcomes achieved with traditional secular interventions.

Evaluating the salience of client spirituality during the initial assessment can be difficult. As a result of fear of being judged, for instance, some clients may be hesitant to share the degree to which they are spiritually committed (Gotterer, 2001). Conversely, in more religious settings, some clients may tend to overstate the importance of spirituality in their lives.

One possible indicator of spiritual salience is the degree to which clients practice the norms of their faith tradition, although this approach requires some degree of cultural competence to implement effectively. Catholics who attend Mass weekly or Muslims who practice the "five pillars," for instance, are likely to be more spiritually committed than Catholics who rarely attend mass or Muslims who sporadically practice some of the five pillars. Another possibility is to use a short quantitative instrument to assess the degree of spiritual motivation, such as the intrinsic measure of religion (Burris, 1999) or spirituality (Hodge, 2003b). Regardless of the method used, if the initial assessment suggests that spirituality functions as an organizing principle in the client's life, then further assessment may be appropriate.

DISCUSSION AND CONCLUSION

As noted, the four principles--client autonomy, cultural competency, spiritual norms and service provision, and spiritual salience--are often held in tension with, and inform, one another. Rather than thinking of the four guidelines as categorical, it may be helpful to think of them as existing along a continuum. Although client autonomy must always be respected, various levels of enthusiasm will exist among those who endorse the idea of a comprehensive assessment. Likewise, cultural competence is best understood as existing along a continuum, with practitioners having various levels of cultural competence with different faith traditions (Dunn, 2002). Similar comments could be made about the intersection between spiritual norms and service provision and the client's level of spiritual salience.

Accordingly, when considering the advisability of administering a comprehensive assessment, each guideline should be considered in the light of the others. For instance, if the client is very interested in integrating his or her spiritual beliefs and values into service provision and his or her level of spiritual salience is high, then a comprehensive assessment may be warranted, even though the practitioner has a moderate level of cultural competence with the client's faith tradition and the intersection between the spiritual norms and service provision is vague. Respect for client autonomy and high levels of spiritual salience may help to mitigate lower levels of cultural competence and an unclear relationship between the client's spiritual norms and service provision.

Within this framework, it is important to reiterate the importance of respecting clients' autonomy (Belcher & Cascio, 2001; Canda & Furman, 1999). Enthusiasm and consent are different constructs. Although clients may report various degrees of enthusiasm for moving ahead with a comprehensive assessment, it is an ethical requirement that clients fully assent to the assessment of their spirituality. Client hesitancy is not a license to continue with an assessment, even if the other three guidelines suggest that an assessment is warranted. Indeed, hesitancy suggests the absence of full consent and, accordingly, indicates that one should not proceed with a comprehensive assessment.

Client reluctance to proceed with an assessment, however, can be sensitively explored, a process that is especially advisable when the other guidelines point toward the importance of a comprehensive assessment. As stated earlier, many clients may be reluctant to proceed with an assessment because of concerns that the practitioner might be disrespectful or otherwise disparage a dimension of their being that they hold sacred (Furman et al., 1996; Gotterer, 2001; Richards & Bergin, 2000). In many cases, social workers, particularly those with high levels of cultural competence regarding the client's faith tradition, can address such concerns, and the assessment can proceed.

As discussed earlier, it is also hard to imagine a situation in which a practitioner would proceed with a comprehensive assessment if the initial assessment revealed that the client was a member of a faith tradition for which the practitioner held a low degree of cultural competence. As the NASW Code of Ethics (NASW, 1999) stipulates that social workers must avoid causing harm to their clients, restricting their practice to areas in which they have some degree of competence. In such situations, referral should be considered.

Although assessment of one's level of cultural competence is generally a subjective endeavor, various resources exist for developing cultural competence (Canda & Furman, 1999; Koenig, 1998; Richards & Bergin, 2000; Van Hook et al., 2001). Practitioners who regularly encounter members of particular faith traditions may wish to familiarize themselves with the norms of these traditions as well as engage in some degree of self-assessment regarding their feeling toward those traditions' beliefs and values (Sahlein, 2002). Sue, Arredondo, and McDavis (1992) suggested that cultural competence is contingent on developing an awareness of one's own values, biases, and assumptions as well as developing an empathetic, unbiased understanding of the client's worldview.

Practitioners may also find it helpful to develop relationships with clergy from various denominations and faith traditions (Gilbert, 2000). Clergy can often assist social workers in clarifying the norms within their particular faith tradition. In addition, they can also be a valuable resource for evaluating various interventions that seek to use clients' spirituality to ameliorate problems, such as those discussed earlier that integrate salutary beliefs from the client's faith tradition into cognitive therapy (Harr, Openshaw, & Moore, in press).

If the situation calls for a comprehensive assessment, several approaches exist (Hodge, 2001). For instance, Hodge (2003c) has developed a complementary set of comprehensive assessment tools, discussed the strengths and limitations of each tool in the set (Hodge, 2005a), and provided a framework to help practitioners select among the various tools (Hodge, 2005c). This toolbox of assessment approaches was designed to be consistent with the JCAHO standards.

The assessment template discussed in this article obviously has the most applicability in JCAHO-accredited settings. Practitioners in many other settings, however, may wish to consider using this approach. The JCAHO model may be an appropriate choice where no formal requirements for spiritual assessment currently exist, especially in settings where there is resistance to the idea of spiritual assessment.

JCAHO's (2004a) mission is to develop state-of-the-art standards that seek to continuously improve the safety and quality of care provided to clients. To this end, NASW participates on JCAHO professional and technical advisory committees (NASW, 2004). As religious diversity has increased in the United States (Melton, 1999), so has the need for spiritual assessment. Consequently, in settings where no spiritual assessment protocols exist, social workers may wish to consider adopting the approach outlined in this article as a way to provide more effective, culturally sensitive services.

Although most social workers endorse the importance of spiritual assessment (Can& & Furman, 1999; Carlson et al., 2002; Prest et al., 1999; Sheridan & Amato-von Hemert, 1999), resistance to spirituality and religion still exists in many areas (Clark, 1994; Sahlein, 2002).JCAHO's status, however, may help counter such resistance. Accordingly, the organization's prestige may provide a certain degree of credibility to social workers and agencies seeking to implement spiritual assessment protocols. The fact that the nation's largest and oldest health care accrediting organization requires spiritual assessments may give pause to those who believe that spirituality is peripheral or unrelated to service provision. Indeed, the template presented in this article should be familiar to all social workers interested in holistic service provision.

Original manuscript received October 28, 2004 Final revision received March 18, 2005 Accepted August 15, 2005

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David R. Hodge, PhD, is assistant professor, Department of Social Work, Arizona State University-West Campus, P.O. Box 37100, Phoenix, AZ 85069-7100, and senior nonresident fellow, Program for Research on Religion and Urban Civil Society, University of Pennsylvania.
Table 1: Spiritual Assessment Questions
Provided by the Joint Commission on
Accreditation of Healthcare Organizations

1. Who or what provides the patient with strength and
hope?

2. Does the patient use prayer in their life?

3. How does the patient express their spirituality?

4. How would the patient describe their philosophy of life?

5. What type of spiritual/religious support does the patient
desire?

6. What is the name of the patient's clergy, ministers,
chaplains, pastor, rabbi?

7. What does suffering mean to the patient?

8. What does dying mean to the patient?

9. What are the patient's spiritual goals?

10. Is there a role of church/synagogue in the patient's life?

11. Has belief in God been important in the patient's life?

12. How does your faith help the patient cope with illness?

13. How does the patient keep going day after day?

14. What helps the patient get through this heath care
experience?

15. How has illness affected the patient and his/her Family?

[c] Joint Commission on Accreditation of Healthcare Organizations, 2004.
Reprinted with permission

Table 2: Brief Assessment Model that
Conforms to the Joint Commission on
Accreditation of Healthcare Organizations'
Spiritual Assessment Recommendations

1. I was wondering if spirituality or religion is important
to you?

2. Are there certain spiritual beliefs and practices that you
find particularly helpful in dealing with problems?

3. I was also wondering if you attend a church or some

other type of spiritual community?
4. Are there any spiritual needs or concerns I can help you
with?

Source: Hodge, D, R (2004). Spirituality and people with mental illness:
Developing spiritual competency in assessment and intervention Families
in Society, 85, 38. Adapted with permission from the Alliance for
Children and Families (www.familiesinsociety.org).
Gale Copyright: Copyright 2006 Gale, Cengage Learning. All rights reserved.