Spirituality Assessments: Limitations and Recommendations
David R. Brown
Brown, David R. is a second-year counselor education doctoral student at Auburn University. David is a licensed professional counselor and a licensed professional Christian counselor, and he is currently studying the assessment of spirituality, especially as it relates to mental health.
Elise P. Johnson
Elise P. Johnson, M.S., is a certified counselor and third-year doctoral student in counselor education at Auburn University. Her research interests relate to spiritual development and assessment, parenting, and school retention and drop-out prevention.
Mark S. Parrish
Parrish, Mark S. is a second-year counselor education doctoral student at Auburn University. Mark is a licensed professional counselor with a clinical background working with those suffering with addictions and juvenile sex offenders. He is currently studying the assessment of professional counselor characteristics and competencies for those clinicians working with Native American populations.
Since the early 1980’s, increased attention has been given to the integration of spirituality into the counseling profession (Cashwell, Bentley, & Yarborough, 2007; Cashwell & Young, 2004; Kelly, Jr., 1994; Miller & Thoresen, 2003; Pate, Jr. & High, 1995). Interest in such an integration of spirituality and counseling first appeared in the late nineteenth century in professional literature through the work of Frank Parsons and Francis Galton (cited in McCormick, 2004). However, it was not until the 1980’s, when spirituality was described as a multicultural issue, that professionals began integrating spirituality into graduate-level counseling courses (Curtis & Glass, 2002; Souza, 2002), holistic wellness models (Adams, Bezner, Drabbs, Zambarano, & Steinhardt, 2000; Sweeney & Witmer, 1991), and assessment instruments (Hall & Edwards, 2002; Hill & Hood, Jr., 1999; Slater, Hall, & Edwards, 2001; Stanard, et al., 2000). Although counseling professionals are beginning to respond to the spiritual needs of the United States’ population, according to recent research by Young, Wiggins-Frame, and Cashwell (2007) interest in integrating spirituality into the counseling profession has increased, but a full integration of spirituality into counseling has not been realized. Additionally, the educational and training response by the counseling profession has not kept pace.
In the 1994 study conducted by Kelly, Jr., Gallup polling indicated that over 80% of the United States population identified with a religious organization at that time. The United States Census Bureau (2006) recently released statistics that continue to support Kelly Jr.’s study. According to the U.S. Census Bureau, a vast majority of Americans identify with a religious organization or actively pursue spiritual activities. These figures indicate that the percentage of those who identify with a religious organization has increased to approximately 86%. Gallup and Lindsay (1999, cited in Miller & Thoresen, 2003) state the following about spirituality in the United States:
About 95% of Americans recently professed a belief in God or a higher power, a figure that has never dropped below 90% during the past 50 years, and 9 out of 10 people also said that they pray, most of them (67%-75%) on a daily basis (p. 24).
Other statistics cited by Miller and Thoresen indicate that “Many Americans have stated that their faith is a central guiding force in their lives” (p. 24). Because such a large percentage of the United States population indicates an interest in spirituality and religion, it is imperative that counselors gain training and competence in spiritual issues.
The concept of spirituality is highly complex as it is understood through personal experience. Definitions of spirituality range from ecstatic, transcendental experiences to existential searches for purpose and meaning. Speck (2005) illustrates this definitional dilemma when stating that “to harmonize these definitions would be a herculean [sic] task because they point to competing worldviews that are not always fully articulated in the literature, helping to explain why the definitions rely on abstractions” (p. 4). For the purposes of this chapter, spirituality will be defined according to that suggested by Burke, Hackney, Hudson, Mirante, Watts, and Epp (1999): a metaphysical / transcendental experience or any experience that brings one meaning, purpose, or into a relationship with a higher being or higher power. This definition also suggests a relationship with religion which represents an organized approach to spirituality. Although many similarities exist, enough differences can be identified to create a different understanding. Therefore, religion will also be defined according to the definition provided by Burke, et al. (1999): a social assembly where like-minded individuals congregate to form an organization where spirituality is experienced through structured beliefs. Although many individuals consider spirituality and religion to be inseparable, the purpose of this chapter is not to differentiate between personal beliefs and practices. This chapter is primarily concerned with the integration of spirituality into the counseling process, the benefits and limitations in assessment instruments, and recommendations for the proper uses of spirituality assessments.
Before discussing specific spirituality assessments in detail, it is important to understand the ethical and legal issues surrounding the development, use, and interpretation of spirituality assessments. The American Counseling Association (ACA) has provided for the integration of spirituality into counseling in a variety of aspects. The ACA Code of Ethics (2005) provides ethical guidelines for the integration of spirituality into the counseling process in areas such as informed consent (Section A.2.a.), developmental and cultural sensitivity (Section A.2.c.), personal values (Section A.4.b.), advocacy (Section A.6.a.), quality of life (Section A.9.a.), counselor competence (Section A.9.b.), multicultural and/or diversity considerations (Section B.1.a.), counselor credentials (Section C.4.b.), non-discrimination (Section C.5.), and evaluation, assessment, and interpretation (Section E.). Many of the ACA divisions define similar areas of spirituality awareness and competence thus requiring members to attend to spiritual issues in the counseling process. The Council for Accreditation of Counseling and Related Educational Programs’ (CACREP) 2001 Standards (2001) provides several core areas of competence for counselor education training programs. These areas include social and cultural diversity (Section II.K.2.), helping relationships (Section II.K.5.), assessment (Section II.K.7.), and standards for counseling programs (Section IV.). Each standard is designed to increase awareness and understanding of spirituality in the counseling profession.
Spirituality Assessment Instruments
Hill and Hood, Jr. (1999) illustrated the increasing interest in spirituality in the counseling profession by publishing a collection of reviews for a large number of published spirituality measures. Reviews are provided for an entire range of assessments: from the short, non-validated, and non-normed instruments to the widely-used and highly-researched instruments. Although many instruments return empirical results, others are designed as qualitative assessments, which Moberg (2002) suggests are more feasible methods for measuring spirituality constructs. However, as Hill and Hood, Jr. suggest, such a large number (126) of spirituality assessments demonstrate the need to understand various constructs of spirituality, the purposes of the assessment instruments, as well their proper use. This section will provide greater information regarding three popular spirituality assessments.
Spiritual Well-Being Scale (SWBS)
The SWBS was first published by Paloutzian and Ellison in 1982 as a measure of quality of life and spiritual well-being. The SWBS is measured on two subscales: religious well-being (RWB) and existential well-being (EWB). RWB focuses on the well-being of spiritual life, as related to an understanding of a “higher being” or God. The EWB is focused upon how well the person is adjusted to life, living, and community. Reliability, specifically internal and test-retest, and face validity are very high on the SWBS although the authors report a “ceiling effect” when it is used to assess some religious samples. In addition, the measure is reportedly “very sensitive” at lower levels. Much research has utilized the SWBS, and the authors claim that over 300 studies have been completed, many of which include culturally diverse populations.
The SWBS offers areas for increased attention and improvement. For example, each question on the RWB subscale includes the word “God,” although reviews claim that it is nonsectarian (Boivin, Kirby, Underwood, & Silva, 1999). However, a significant strength of the SWBS is that it may be used in a variety of contexts (Boivin, et al., 1999). Research has been conducted on numerous populations, such as
The numerous research populations suggest that this assessment is useful in a variety of contexts and also appears to return valid data. As research using the SWBS increases, counselors and other mental health professionals would benefit from a technical user’s manual describing the instrument’s development, psychometric properties and recommended uses.
Index of Core Spiritual Experiences (INSPIRIT)
The INSPIRIT was designed to identify more intense and concrete experiences related to the existence of God or a Higher Power by respondents. The INSPIRIT measures characteristic elements of core spiritual experiences by identifying a distinct spiritual event and the subject’s cognitive appraisal of that event which is reported to have resulted in a personal conviction of God’s existence . The instrument focuses on the perception of a highly internalized relationship with God (or a Higher Power) , and the concurrent core spiritual experiences which establish a potential connection with health outcomes ( Kass, Friedman, Lesserman, Zuttermeister, & Benson, 1991). The reported psychometric properties indicate a strong degree of internal reliability and concurrent validity with convergent and discriminant validity being supported by comparisons of several other scales (Stanard, et al., 2000). Additionally, Kass, et al. (1991) report that the INSPIRIT differentiates in a client’s length of history of meditation along with the core spiritual experience.
The accumulated results of reliability and validity testing suggest that a client ’s spiritual experiences and subsequent perceived level of spirituality may contribute to: (1) positive psychological attitudes; (2) reduction of medical symptoms; (3) improved quality of life less burdened by illness; (4) less depression; (5) greater life satisfaction; (6) lower blood pressure; (7) lower mortality rates from coronary artery disease and cardiac surgery; (8) improved obstetric outcomes; and, (9) the utilization of fewer health services in general (Kass, et al., 1991; Stanard, et al., 2000; Shapiro, Schwartz, & Bonner, 1998).
Since the research appears to indicate that spirituality may be an important mediator of both physical and mental health, the INSPIRIT scale may help to quantify some perceived aspects of spirituality within clients and is thus potentially useful in assessing the client’s intrinsic tools for self-improvement of health. Additionally, the instrument may be useful in stimulating discussion of issues related to counseling and integrating the subsequent findings into the treatment planning process.
Although the INSPIRIT appears to be a promising brief instrument for assessing spirituality in mental health clients (Stanard, et al., 2000), the instrument’s small sample size and norming sample limit the reliable use with certain clients. It appears to lack diversity in its norming sample related to respondents’ level of education and minority representation and should be used cautiously when generalizing results to the population at-large. Continued research is necessary to address these limitations.
Spiritual Assessment Inventory (SAI)
The SAI was developed to measure an individual’s spiritual development, or spiritual maturity, from both an object relations and a contemplative spirituality perspective. The instrument was intended for use in clinical as well as research settings and is grounded in theological, or spiritual, as well as psychological foundations (Standard, et al., 2000). Hall and Edward (1996) describe the SAI as being used to “measure both the spiritual and psychological aspects of spiritual maturity defined in the context of one’s experienced relationship with God” (p. 244). The characteristic elements of spiritual maturity include: (1) different developmental levels of an individual’s personal relationship with God (Quality of Relationship subscale), and (2) the degree of an individual’s awareness of God in his or her life (Awareness subscale) (Hall & Edwards, 1996, 2002).
Similar to attachment theory, object relations theory represents a modern adaptation of psychoanalytic theory that places less emphasis on aggressive or sexual drives as motivational forces and more emphasis on human relationships as the primary motivational life force. Object relations theorists believe that people are relationship seeking rather than pleasure seeking as Freud suggested (Hall & Edwards, 1996). The importance of relationships in the theory translates to relationships as the focal point of psychotherapy, especially the therapeutic relationship. Theoretically, the SAI is congruent by attempting to measure one’s relationship with God, or a Higher Power.
With the exception of one of the five scales, the reported psychometric properties indicate a strong degree of internal reliability. Construct validity is supported by correlation results with the Bell Object Relations Inventory (BORI), an instrument developed using a similar theoretical basis. The instrument is brief, easy to administer and score, and is grounded in a solid theoretical foundation (Standard, et al., 2000).
The SAI has been criticized for its small test-retest reliability samples. Furthermore, the data collected from the norming sample provides limited information outside of a highly educated, Judeo-Christian framework. Tisdale (1999) cited a need to further define spiritual maturity as well as the two dimensions on which it is based. Being a fairly new instrument, the authors agree that research is ongoing and the development continues to be in the process of revision. Based on initial data, the SAI has been commended for its sound theoretical base and apparent utility with “religious college students” (Tisdale, p. 368).
Many reasons exist for addressing the spiritual needs of clients. Spirituality assessments provide a systematic approach to addressing an often overlooked yet vital element of client assessment and treatment. They can also provide a method of identifying spiritual assets that can help to conceptualize treatment issues, planning and intervention (Standard, et al., 2000). Addressing spiritual needs in counseling can bridge the gap between behavioral, cognitive, and humanistic approaches to assessment by promoting a positive, holistic model to treatment planning and intervention. Including the assessment of spiritual needs ensures a multicultural system where diversity is valued and differences are embraced in the assessment and counseling processes (ACA, 2005). Counselors are able to target specific needs and help determine areas of improvement not typically addressed through traditional counseling models. This may offer new insights to clients about making meaning of their lives. Talking with clients about spiritual issues may also help them assess their current level of mind-body-spirit wellness which can promote increased self-understanding. Including spiritual assessment in a battery of tools promotes professional research and provides more reliable and valid measures for future scholarship.
Spirituality assessment is not unique to the mental health profession. In fact, assessing spiritual needs is common in health care settings and has been shown to benefit patients in numerous ways. Research results show that addressing spiritual concerns have made patients’ health care experiences more positive. It promotes a more therapeutic relationship between the patient and health care professional. Assessing spirituality can promote health and wellness while providing patients with a framework for making important health care decisions (Ehman, Ott, & Short, 1999). Studies have shown decreases in depression for many patients while helping them effectively cope with difficult illnesses. Simply acknowledging the spiritual wishes and needs of patients has resulted in improved outcomes for some patients. As a result, many patients are able to find meaning in their specific situations as well as in life overall (Joint Commission on Accreditation of Healthcare Organizations, 2005).
According to Stanard, et al. (2000), many of the spiritual assessments being widely used today are based “on a Judeo-Christian perspective or a belief in God or a Higher Power as the basis of measurement” (p. 209). Therefore, the results are not fully representative of the general population and may not accurately address a client’s spiritual issues or needs at all. Additionally, counselors must consider the information they are seeking; as suggested by Moberg (2002), a qualitative instrument may provide more useful information than a quantitative measure. The instruments outlined in this article measure spiritual constructs which are viewed as specific pieces to a more complex spiritual whole. These measurements provide a limited perspective to the much larger concept of spirituality. Although the SAI, INSPIRIT, and SWBS appear to possess strong psychometric properties, many of the other published spiritual assessments have small norming samples, are not well-constructed, and cannot be deemed either reliable or valid.
As is true with any formalized instrument, discretion is imperative when choosing and administering spirituality assessments. Some published spirituality assessments do not report norming or validity data (Hill & Hood, Jr., 1999). Some measures, reported by Hill and Hood, Jr., are acknowledged and strictly defined as research instruments and should not be used without careful consideration. Therefore, knowledge of the intended use of the assessment and determining the specific construct to be measured relative to the client’s needs are essential. The ACA Code of Ethics (2005) requires that
Therefore, it is imperative that counseling professionals understand the limitations of any spirituality assessment that is used either in research or for counseling purposes. Some instruments, such as the SWBS, may be useful with a variety of populations, however, other instruments, such as the SAI, may require more research and revisions before it is useful in the counseling process.
Regarding counselor education programs, evidence exists for the need to provide more formalized training in spirituality and spirituality assessment. Counselors-in-training, as well as professionals in the field, would benefit from specialized instruction related to assessing and addressing clients’ spiritual needs. Because the concept of spirituality is becoming more widely accepted as an integral component of counseling (Young, et al., 2007) and multicultural and diversity training (ACA, 2005), guidance in the use of spirituality assessment will become not only useful but imperative to the clients’ lives with whom counselors work. Current research appears to strongly suggest that spirituality is an important factor in the counseling process (Burke, et al., 1999; Cashwell, et al., 2007; Cashwell & Young, 2004; Kelly, Jr., 1994; Miller & Thoresen, 2003; Moberg, 2002; Stanard, et al., 2000; Young, et al., 2007), which strongly supports the usefulness of spirituality assessments. As the emerging field of spirituality in counseling becomes a mainstream aspect of counseling, spirituality assessments will play a greater role in the holistic assessment process.
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