Matters of the Spirit - Spiritual Assessments In Counseling

Matters of the Spirit

Running head: MATTERS OF THE SPIRIT

Matters of the Spirit:

Spiritual assessments in counseling

Myrna D. Washington

Ashford University

PSY 360 Survey of Mental Health

Instructor: Matthew Gale

August 4, 2008

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Table of Contents

Abstract …………………………………………………………………………. Page 3

Introduction …………………………………………………………………………. Page 4

Literature Review ……. ………………………………………………………………… Page 5

What is Mental Health? ………………………………………………………. Page 5

What is Mental Illness? ………………………………………………………. Page 5

What is Spirituality? …..………………………………………………………. Page 5

What are the Benefits of Spirituality?

............................................................... Page 6

Empirical Evidence ……………………………………………………………. Page 6

Spiritual Dimensions of Theoretical Perspectives ………………………………………

Page 7

Spiritual Assessment Instruments ………………………………………………………. Page 8

Qualitative Spiritual Assessments ……………………………………………… Page 10

Quantitative Spiritual Assessments ……………………………………………. Page 11

Toward the Future ………………………………………………………………………. . Page 13

References ………………………………………………………………………………… Page 14

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Abstract

In the dawn of the twenty-first century, the focus of spirituality has

gravitated from the dark and personal toward the universal light. In the dawning of

this light, 95% of Americans believe in God and 75% report that spirituality and

religious faith are the most important influences in their lives. As both a

coping mechanism and an assessment instrument, spirituality has emerged from

its enigmatic closet and is now ‘living out loud’. Matters of the personal

spirit have become matters of the universal spirit. This paper defines the

relationship between spirituality and mental health, examines the theoretical

perspectives of spirituality in the counseling process, and explores some of

the available spiritual assessment tools in modern counseling.

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Matters of the Spirit: Spiritual assessments in counseling

In the dawn of the twenty-first century, the focus of spirituality has

gravitated from the dark and personal toward the universal light. In the dawning of

this light, 95% of Americans believe in God and 75% report that spirituality and

religious faith are the most important influences in their lives (Spiritual

Competency Resource Center [SCRC], 2008). As both a coping mechanism and an

assessment tool, spirituality has emerged from its enigmatic closet and is now

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‘living out loud’. Matters of the personal spirit have become matters of the

universal spirit.

In addressing multicultural assessment and intervention, the American

Psychological Association’s Guidelines for Providers of Psychological Services to Ethnic,

Linguistic and Culturally-diverse Populations (APA Online, 2008) requires psychologists to

“respect clients’ religious and/or spiritual beliefs and values, including

attributions and taboos, since they affect world view, psychosocial

functioning, and expression of distress” (APA Online, 2008). In support of

this, “60% of APA psychologists state that clients often expressed their

personal experiences in religious language, 1 in 6 presented issues which directly

involved spirituality or religion, and 72% indicated that they had at some

time addressed religious or spiritual issues in treatment” (SCRC, 2008).

Indeed, recent scientific research has given scientific credibility to

the emerging trend of spirituality in all phases of the counseling process by

supporting a positive correlation between spirituality and mental health.

This published empirical data suggests that “spiritual/religious commitment

plays a significantly beneficial role in preventing mental and physical

illness, improving how people cope with mental and physical illness, and

facilitating recovery from illness” (SCRC, 2008).

In addition, members of the helping professions have become

increasingly interested in the benefits of spirituality as a coping mechanism

and as a source of strength and guidance in their clients’ times of mental,

physical and emotional distress. As an evolving perspective in

multiculturalism, spirituality is an emerging dimension of the assessment

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process that can be used as a tool to gain insight and understanding of the

client’s world, promote self-realization and self-improvement, and foster a

strengths perspective.

In this paper, we will define the relationship between spirituality and

mental health, examine the theoretical perspectives of spirituality in the

counseling process, and explore some of the available spiritual assessment

tools in modern counseling.

Literature Review

What is Mental Health?

The World Health Organization (WHO, 2008) defines mental health as “a

broad array of activities directly related to a state of complete physical,

mental and social well-being in which every individual realizes his or her own

potential, can cope with the normal stresses of life, can work productively

and fruitfully, and is able to make a contribution to his or her community”.

“Mental health is related to the promotion of well-being, the prevention of

mental disorders, and the treatment and rehabilitation of people affected by

mental disorders” (WHO, 2008).

What is Mental Illness?

According to O’Reilly (2004), “the organic, cognitive, and emotional

events of mental illness derail the process of becoming; diminish the client’s

ability to perceive internal and external relatedness; and result in an

experience of existential aloneness, helplessness, and pointlessness. Mental

illness is thus proposed as a disruption of the body, mind, and spirit that

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results in pain and impaired functioning in all dimensions of the human

experience” (para. 8).

What is Spirituality?

O’Reilly (2004) defines spirituality as “an experience for connection to

life; a way of interpreting life events; and as a source of hope, joy,

comfort, and guidance on life’s journey. Spirituality may be expressed

through a relationship with a Supreme Being; sought through experiences such a

religious rituals, the arts, or altruistic activities, or experienced through

feelings of acceptance and wonder at life’s offerings” (para. 6).

Hodge (2005b) describes spirituality as “an existential relationship with

God (or perceived Transcendence) that fosters a sense of meaning, purpose, and

mission in life. In turn this relationship produces salutary change, such as

an increased sense of other-centered love, which has a discernible effect on

an individual’s relationship to self, others, and God (para. 4).

Richards and Bergin (as cited in Nystul, 2006) conceptualize spirituality as

the “invisible phenomena associated with thoughts and feelings of

enlightenment, vision, harmony with truth, transcendence, peak experiences,

and oneness with God, nature, or the universe” (p. 20). The Royal College of

Psychiatry (RCP, 2006) further identifies spirituality with “experiencing a

deep-seated sense of meaning and purpose in life, together with a sense of

belonging, acceptance, integration and wholeness” (para. 1).

O’Reilly (2004) describes spirituality in terms of what it provides:

“Spirituality enhances inner resources and sense of self, provides meaning to

the experience of suffering, supports relatedness to others, and is an

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expression of the transcendent ways in which human potential is fulfilled”

(para. 6).

What are the Benefits of Spirituality?

According to the RCP (2006, para. 9), the benefits of spirituality in

patient care are: 1) improved self-control, self-esteem and confidence; 2)

faster and easier recovery, achieved through both promoting the healthy

grieving of loss and maximizing personal potential; 3) improved relationships

– with others and with God/creation/nature; and 4) a new sense of meaning,

resulting in reawakening of hope and peace of mind, enabling people to accept

and live with problems not yet resolved.

From these perspectives, although spirituality and religion are

interrelated and interchangeable terms, one does not have to be religious to

be spiritual. In fact, religion (from the Latin religare, meaning ‘to bind

back’) is a discipline or practice; spirituality is a concept or belief

connecting the conscious with the unconscious, the personal with the

universal, the one with the whole, and the individual with the collective.

Spirituality is expressed through and bound by religion; religiosity is not a

requirement of spirituality. “Religion flows from spirituality” (Hodge,

2005b, para. 4).

Empirical Evidence

According to Psychiatric Annals (as cited in SCRC, 2008), 79% of

Americans believe that spiritual faith can help one recover from illness,

injury or disease; 56% believe their faith helped them recover from illness,

injury or disease; and 63% believe doctors should talk to patients about their

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spiritual faith. In addition, 80% of psychiatry patients consider themselves

to be spiritual or religious and in need of prayer, 48% consider themselves to

be deeply religious, and 68% believe spirituality and religion is a source of

strength and comfort.

Koenig et al (as cited in SCRC, 2008), state that “religious practices

such as worship and prayer appear to protect against severity of psychiatric

symptoms and hospitalization, and enhance life satisfaction and speed recovery

in mental disorders”. According to Kirov, Kemp, Kirov & David (as cited in

SCRC, 2008), out of 74 patients with acute psychotic symptoms, 30.2% reported

and increase in spiritual/religious faith after the onset of the illness and

61.2% reported they used spirituality/religion to cope with their illness and

to get better. Finally, Lindgreen & Courtsey (as cited in SCRC, 2008) report

that 83% of psychiatric patients felt that spiritual beliefs had a positive

impact on their illness through the comfort it provided and the feelings of

being cared for, and the feelings of not being alone it engendered.

Spiritual Dimensions of Theoretical Perspectives

Theoretical support for the spirituality model in the assessment process

of counseling include Abraham Maslow’s hierarchy of motivational needs,

Alfred Adler’s individual psychology, Carl Jung’s analytic psychology, and

Experiential Therapies (i.e. Carl Rogers, Existential Therapy and Creative

Arts Therapies).

Abraham Maslow's hierarchy of motivational needs is a pyramid-shaped

model with the physiological needs at the base and higher level needs at the

top. According to this theory, “before more sophisticated, higher-order needs

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can be met, certain primary needs must be satisfied” (Feldman, 2008, p. 325).

Maslow gives spirituality a high priority (level 3); after the primary

physiological needs for food, water, sleep, sex, and shelter. At this level,

Maslow examines the need to give and receive affection. However, something

more divine is at play here. The gravitational pull of the collective

supersedes any sense of existing as separate from the collective, and the

conscious inclination will always be to seek validation and unconditional

acceptance of the collective, whether we are aware of it or not.

Huitt (2001) writes:

Maslow's basic position is that as one becomes more self-actualized and

self-transcendent, one becomes more wise (develops wisdom) and

automatically knows what to do in a wide variety of situations. Daniels

(2001) suggests that Maslow's ultimate conclusion that the highest

levels of self-actualization are transcendent in their nature may be one

of his most important contributions to the study of human behavior and

motivation.

In accordance with the spiritual model, Alfred Adler’s individual psychology

takes an optimistic approach to human nature, focusing on the dignity and

worth of each individual, the creative self, social interest, holistic psychology,

and striving for significance. The major goals of Adlerian psychotherapy

include: “increasing the client’s social interest, helping clients overcome

feelings of discouragement and reducing inferiority feelings, modifying

clients’ views and goals and changing their life scripts, changing faulty

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motivation, helping clients feel a sense of equality with others, and

assisting clients to become contributing members of society” ( Nystul, 2006,

p. 189). Adlerian counseling techniques consist of four-phases: 1)

establishing a relationship (using listening skills, winning respect and

offering hope, and encouragement); 2) performing analysis and assessment

(conducting a lifestyle analysis to correct basic mistakes); 3) promoting

insight (interpretation and confrontation); and 4) reorientation (i.e.,

spitting in the client’s soup, the push-button technique, catching oneself,

acting as-if, and task setting and commitment) (pp. 190-192).

Carl Jung’s works serve as the foundation for Existential Analysis,

Experiential Counseling, Creative Arts Therapies, the Self-Realization

Movement, the Holistic Health Movement, and the 12-step Program (i.e.,

Alcoholics Anonymous, Overeaters Anonymous. According to Nystul (2006), "Jung

had a positive view of the human condition, believing that people had inherent

tendencies toward individualization - becoming unique individuals capable of

wholeness and self-realization. This process of individualization is

characterized by a union or integration of conscious and unconscious

processes" (p. 196).

Jung divided the psyche into three parts: the ego, the personal unconscious,

and the collective unconscious; Spirituality connects the personal and the collective

unconscious.

. In accordance with Abraham Maslow’s hierarchy of motivational needs,

Adler believed in social factors and the desire to belong or feel connected

and loved and Jung emphasized the unconscious, both personal and collective.

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For Jung “wholeness and psychological balance occur when the conscious and

unconscious mind learn to work in harmony” (Nystul, 2006, p. 200).

As an experiential approach, creative arts therapy is, perhaps, the most

spiritual of all; experiential counselors use the creative arts (music, art,

dance, drama, and bibliotherapy) to help their clients discover strengths that

they can use to enhance their psychological functioning’ (Nystul, 2006, p.

204). In order to foster therapeutic bonding, empathy, immediacy, and

authenticity in the counseling process, experiential counselors use flexible,

humanistic, person-centered modalities. This fosters transcendence, self-

growth, self-awareness, self-realization, existential encounters between

client and counselor, and the strengths perspective.

Spiritual Assessment Instruments

Because spirituality is such a recent dimension of multiculturalism, its

assessment is still in the infancy stages of development. Nystul (2006, p.

115) writes:

By considering the spiritual and/or religious beliefs and practices of

the client, the counselor can: 1) move beyond the intrapsychic or self-

analysis; 2) gain an understanding of the client's worldview regarding

spiritual issues; 3) determine whether the client's spiritual beliefs

and values are healthy (intrinsically motivated and characterized by

personal spiritual journeys with individualized goals and aspirations)

or unhealthy (extrinsic religious orientation that includes people who

use religion as a way of impressing others with status and self-

righteousness) in terms of promoting mental health: and 4) determine

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whether the client perceives spirituality as a source of strength and

guidance and whether they turn to spiritual processes during times of

personal difficulties.

According to O’Reilly (2004) “tools used in spiritual assessment must be

unobtrusive and nonjudgmental, adaptable to client context and need, and are

worded so as to encourage participation and convey respect” (para. 15)

One of the most widely used spiritual assessment tools is the Diagnostic

and Statistical Manual of Mental Disorders (the DSM-IV-TR), a manual published

by the APA covering all mental health disorders for both children and adults.

It is considered to be the 'bible' and the 'ultimate guide to mental

disorders' for all clinicians making professional diagnoses. In addition to

listing "known causes of these disorders, statistics in terms of gender, age

at onset, and prognosis as well as some research concerning the optimal

treatment approaches, (it is also used to settle disputes among clinicians)

when incongruence and inaccurate information (arise during diagnoses)"

(Heffner, 1999). The DSM-IV is used by the clinicians to: "1) provide

communication shorthand among clinicians, 2) suggests treatment possibilities,

3) communication information about etiology (cause), and 4) aid scientific

investigation" (Nystul, 2006, p. 103).

‘In 1994, in an effort to create a new psychological perspective and

increase awareness of the theoretical issues involved in spirituality (as well

as its practical applications for professional care), the APA (DSM-IV)

introduced a new diagnostic category which mentions spiritual or religious

problems as the focus of clinical attention’ (Nino, 1997, para. 6). The

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examples given include: “distressing experiences that involve loss of

questioning of faith, problems associated with conversion to a new faith, or

questioning of spiritual values that may not necessarily be related to an

organized church or religious institution” (Nino, 1997, para. 7).

Richards and Bergin (as cited in Nystul, 2006) recommend that the

spiritual assessment be done "during the initial history-taking and clinical

interview" (p. 115). Nystul (2006) suggests priming the assessment process by

asking these three questions: "1) From the perspective of (your) culture, how

is mental health and mental illness conceptualized? 2) How can your culture,

religion, and spirituality be used to explain how you developed your mental

health problems? and 3) How can your culture, religion, and spirituality be

used to help you get better?" (p. 114).

Nystul (2006, pp. 108-110) outlines a four-stage clinical interview of

overlapping functions to address these threats to the accuracy of clinical

diagnoses:

1) Using listening skills to obtain a phenomenological understanding of

the client;

2) Taking an in-depth client history to explore possible organic

factors, provide background information about work, family, social

relationships, health, or important turning points in the clients life

and to explore the client's symptoms and concerns (i.e. difficulty

sleeping, loss of appetite, or marital problems, in terms of onset,

duration, and severity);

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3) Conducting a mental status exam to explore whether the client has

other symptoms associated with Axis II disorders (i.e. delusions, flat

or inappropriate, associated with schizophrenia); and

4) Using standardized and nonstandardized measures to refine diagnostic

considerations and plan treatment.

Qualitative Spiritual Assessments

Hodge (2005a) has created five qualitative spiritual assessment

instruments (one verbally-based approach and four diagrammatic or graphic

approaches) and three quantitative assessment instruments. The qualitative

assessments are: 1) spiritual histories, 2) spiritual lifemaps, 3) spiritual

genograms, and 4) spiritual ecograms. The three quantitative assessments are:

1) the Spiritual Well-being Scale, 2) the Religious Orientation Scale, and the

3) Intrinsic Spirituality Scale). In addition, Hodge (2005a) introduces two

approaches to be used in marriage and family therapy: Intergenerational

Approaches and Present/Life History-Oriented Approaches. The choice of which

assessment tool to use is based upon such intertwined factors as theoretical

orientation, the service setting, the client’s presenting problem and

relational style, and timeframes.

The spiritual history is a verbally-based approach, analogous to

conducting a family history. ‘It consists of two sets of questions designed

to provide a holistic spiritual assessment: 1) an initial narrative framework,

which provides therapists with some possible questions to help clients tell

their stories, from childhood to present; and 2) an interpretive

anthropological framework, designed to elicit information about each of the

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six dimensions: affect, will, cognition, communion, conscience, and intuition’

(Hodge, 2005a, para. 19). Koenig (as cited in O’Reilly, 2004) notes that

“taking a spiritual history is often a powerful intervention in itself. A

spiritual history can bring about alleviation of suffering, personal growth

through difficult experiences, and a decreasing sense of isolation as the

sense of connectedness grows” (para. 18).

Spiritual lifemaps, on the other hand, represent “a diagrammatic

alternative to the verbally-based spiritual histories; “a pictorial

delineation of a client’s spiritual journey” (Hodge, 2005a, para. 23). “In a

manner of speaking, spiritual lifemaps are an illustrated account of the

client’s relationship with God (or Transcendence) over time – a map of their

spiritual life. Much like roadmaps, spiritual lifemaps tell us where we have

come from, where we are now, and where we are going” (Hodge, 2005a, para. 23).

Although spiritual histories and lifemaps generally depict a single

generation, spiritual genograms are modified family trees (blueprints of

complex intergenerational spiritual interactions) that illustrate the flow of

spiritual patterns across at least three generations in a manner analogous to

traditional genograms” (Hodge, 2005a, para. 27).

‘Spiritual ecomaps focus on the clients’ current, existential, spiritual

relationships (Hodge, 2005a, para. 31); Spiritual ecograms combine the

assessment strengths of spiritual ecomaps and genograms in a single assessment

approach’ (Hodge, 2005a, para. 35).

Intergenerational approaches, which use either spiritual genograms or

spiritual ecograms, are used to distinguish between “nuclear families” and

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“extended families” and “provide valuable information on how the family’s

spirituality affects relationship dynamics, family rules, and their worldview.

They also demonstrate respect for the importance of extended family members,

which can enhance levels of social validity (Hodge, 2005a, para. 45).

If more present-oriented factors are considered to be of primary

importance, then the therapist may decide to use present/life history-oriented

approaches, such as spiritual ecomaps, spiritual lifemaps, or spiritual

histories. Spiritual lifemaps appeal to more artistically-oriented clients

and are the most client-directed of all the assessment tools because they

depict the client as competent, proactive, self-directed, and fully engaged in

the therapeutic process (Hodge, 2005a, para. 50).

Quantitative Spiritual Assessments

The three quantitative assessment approaches may be used to supplement

the qualitative approaches by tapping distinct dimensions of client

functioning. The Spiritual Well-Being Scale (Hodge, 2005a, para. 60), a 20-

item scale, measures two dimensions: 1) the vertical dimension, which assesses the

quality of one’s existential relationship with God and 2) the horizontal

dimension, which assesses the quality of one’s relationship with people. The

Religious Orientation Scale (para. 61) is a 21-item scale, designed to assess

the degree to which religion functions as a ‘master motive’ and the Intrinsic

Spirituality Scale (para. 62) is a 6-item measure which assesses spiritual

motivation.

Nino’s Spiritual Quest is an integrated assessment tool “rooted in a

normative developmental process in which a person negotiates fundamental

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questions that emerge along with characteristic tasks and events of adulthood

toward the formation of individual meaning” (Nino, 1997, para. 20). It

focuses on three major areas of psychological inner life: 1) inwardness, which

includes fundamental strivings, interrogation of memories, and internal

cohesiveness; 2) relatedness, which includes the ultimate other and the

empathetic experience; and 3) generativity, which includes continuity,

disruptions and closures, the vulnerable self, and a critical balance in the

life structure (Nino, 1997).

The spiritual quest is explored with the help of The Spiritual Quest

Form, “a sentence completion task that elicits a projection of the ‘élan

vital, of the core self on issues common to the reflective attitude of most

adults. A dialog follows in which the professional and the subject join

efforts together, creating an empathic environment” (Nino, 1997, para. 84).

The methodology includes the experiential context, working through questions

and engagements, and the personal narrative project (Nino, 1997).

Although the mental status exam is not a definitive spiritual

assessment, it can be used to define the client’s worldview and spiritual

orientation. “Trapacz and Baker (as cited by Nystul, 2006) describe six

components that should be addressed in a mental status exam: 1) appearance,

attitude, and activity level, 2) mood and affect, 3) speech and language, 4)

thought process, thought content, and perception, 5) cognition, and 6) insight

and judgment” (p. 109).

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Another assessment with capabilities for spiritual assessment is the

Multicultural Assessment Procedure (MAP). According to Nystul (2006, pp. 95-

96):

In 1998, Ridley, Li, and Hill developed the MAP to address these

cultural issues and to serve as a culturally specific/sensitive

framework for assessment and diagnosis. The four phases of the MAP are:

"1) identifying cultural data (through listening skills, encouraging

clients to tell their story, and the clinical interview); 2)

interpreting cultural data to formulate a working hypothesis (by

differentiating cultural data from idiosyncratic data; 3) incorporating

cultural data to test the working hypothesis (integrating culturally

relevant information with commonly used clinical procedures such as

medical examinations, psychological testing, and the use of the DSM-IV-

TR diagnostic system); and 4) arriving at a sound assessment decision

(creating a comprehensive, culture-inclusive profile of clients from

which clinical decisions can be made).

Two alternative empirically validated treatment planning models are

based on the acronyms DO A CLIENT MAP and BASIC I.D. These assessments aid

the counselor in looking “beyond intrapsychic forces to gain a broader picture

of the client's world” (Nystul, 2006, p. 115). DO A CLIENT MAP was developed

in 1998 by Linda Seligman and includes consideration of 'diagnosis,

objectives, assessments, clinician characteristics, location of treatment,

interventions, emphasis of treatment, nature of treatment, timing, mediations,

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adjunct services, and prognosis' (p. 112). BASIC I.D. was developed by Arnold

Lazarus in 1997 and includes consideration of 'behavior, affect, sensation,

imagery, cognition, interpersonal relations, and drugs' (p. 112).

Toward the Future

As we move toward the future, postmodern trends in mental health

counseling must work to include the interpersonal, systemic, and sociocultural

forces that define the client’s worldview. In the assessment process, the

etiology of the client’s problems should emphasize process over content and

focus on relational/contextual perspectives. (Nystul, 2006, p. 449). “The

counselor and client should “function as coinvestigators interested in

discovering patterns of meaning that can generate insight and understanding”

(p. 448).

Spiritual assessments provide the basis for establishing and structuring

the client’s relationship with his/her own world. In times of personal

difficulty, spirituality can provide the client with the strength, resiliency,

and guidance necessary to bolster self-esteem and self-efficacy, and move the

client toward healing, health and wholeness. In times of ‘gloom and doom’

spirituality has the capacity to move the client from darkness and despair

into light and self-realization. Spiritual assessments differentiate between

healthy and unhealthy spirituality, and provide a safeguard against the use of

spirituality in a negative, self-aggrandizing manner.

As we have seen, most Americans and most mental health counselors

believe in God and the use of spirituality in the counseling process. There

is a growing body of empirical evidence to support the positive correlation

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between spirituality and mental health. Yet, many counselors and therapists

are reluctant to incorporate spirituality into the counseling process.

Perhaps this is due to lack of knowledge and training about available

assessment tools. Regardless of the reasons, it is still the therapist’s

ethical responsibility to be aware of, assess and utilize all of the social

and cultural differences that impact the client’s treatment and understanding

of his/her world.

References

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http://allpsych.com/disorders/dsm.html

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