THE IMPORTANCE OF educational content on spirituality and religion
is increasingly recognized (Hodge & Derezotes, 2008; Scales et al.,
2002). Although a number of factors underlie this recognition, a central
rationale is the profession's growing emphasis upon diversity and
culturally competent service provision (Krentzman & Townsend, 2008).
The importance of culturally competent practice is reflected in social
work's ethical (National Association of Social Workers [NASW] Code
of Ethics, 1999), professional (NASW Standards for Cultural Competence
in Social Work Practice, 2001), and educational standards (Council on
Social Work Education [CSWE], Educational Policy and Accreditation
Standards, 2008). For instance, CSWE's Educational Policy and
Accreditation Standards require social work programs to educate students
to engage diversity and difference in practice as one of its 10 core
competencies (Educational Policy, 2.1.4).
Native Americans--like many other cultural groups (Richards &
Bergin, 2000; Van Hook Hugen, & Aguilar, 2001)--tend to operate from
a different worldview compared to the dominant secular culture (Coates,
Gray, & Hetherington, 2006; French, 2004; Whitbeck, 2006). Although
spirituality is often compartmentalized in mainstream discourse, it
permeates Native culture (Gilgun, 2002; Miller, 2003). Although it is
important to acknowledge that considerable diversity exists among the
hundreds of indigenous tribes in the United States--each with its own
culture--spirituality is woven into the fabric of most tribal worldviews
(Fuller-Thomson & Minkler, 2005; Trujillo, 2000). Cross' (2001)
observation that "we are spirits on a human journey" (p. 10)
captures the foundational nature of spirituality and the interconnected
nature of the universe. Spirit, mind, body, and environment or context
are all holistically and seamlessly interconnected (Brave Heart, 2001;
Frame, 2003; Graham, 2002).
The extant research suggests most social work students,
practitioners, and educators acknowledge the importance of spirituality
in service provision (Canda & Furman, 2010; Kvafordt & Sheridan,
2007; Murdock, 2005; Sheridan, 2004; Sheridan, 2009; Sheridan &
Amato-von Hemert, 1999). Yet, most respondents in these studies also
report receiving little, if any, educational training on the topic
during their graduate programs. The paucity of training in spirituality
is compounded by the lack of empirical content on culturally competent
practice with Native Americans. In her search of the literature, Weaver
(1999) reported that she was unable to find any empirical work on
cultural competency with Native Americans.
The lack of educational content on addressing Native American
spirituality is a significant oversight. Native Americans are a growing
population that social workers are disproportionately likely to
encounter (Harris, Edlund, & Larson, 2005; Weaver, 2004). Because of
the historical legacy of colonization, oppression, and historical
trauma, Native Americans wrestle with many mental health challenges
(Weaver & Brave Hart, 1999; Yellow Bird, 2004). Consequently, Native
Americans have perhaps the highest levels of service use of any major
population in the United States (Harris et al.). Given that social
workers are increasingly likely to encounter Native clients, it seems
particularly important to expose future practitioners to educational
content that will assist them to work with Native clients in an
effective, culturally competent manner.
Indeed, CSWE's (2008) Educational Policy and Accreditation
Standards suggest that students are expected to identify, analyze, and
implement effective practice strategies with people from diverse
cultures (Educational Policy, 2.1.10[a]-[d]). In the context of serving
Native clients, this typically means addressing the spiritual dimension.
Health and wellness occur when the complex interplay between spirit,
mind, body, and context is in balance and harmony (Cross, 1997; Napoli,
1999; Weaver, 2002). Because of this interconnected, relational
understanding of reality, one dimension affects the others.
Psychological well-being cannot be abstracted from the spiritual (Limb
& Hodge, 2008). In many cases, psychological challenges can only be
overcome by treating the spiritual dimension (Cross, 2001). Thus, to
identify and implement effective practice strategies with Native
clients, it is necessary to conduct a spiritual assessment (Cross, 2001;
Gesino, 2001; Napoli, 1999; Weaver, 2002). Because of the complex
linkage between spirituality and wellness, a spiritual assessment must
be incorporated into essentially all work with Native clients (Gone,
2004; Weaver, 2005). Such an assessment serves as a vehicle for
understanding these linkages while laying the foundation for subsequent
practice decisions, including the design and implementation of effective
practice strategies (Hodge, 2001a).
Most social work students and practitioners appear to recognize the
importance of conducting spiritual assessments, (Sheridan, 2009;
Sheridan & Amato-von Hemert, 1999). but they also appear to have
received little educational training on the topic (Sheridan, 2009;
Sheridan & Amato-von Hemert, 1999). This is of particular concern in
light of the recent accreditation changes implemented by the Joint
Commission--the largest health care accrediting organization in the
United States (Hodge, 2006).
The Joint Commission now requires spiritual assessments in
behavioral health care organizations providing addiction services,
hospitals, and other facilities frequented by Native Americans (Hodge,
2006; Koenig, 2007). In theory, this represents a progressive step
toward a more culturally congruent service provision. If, however,
social work practitioners are required to conduct spiritual assessments,
it is critical that social work students receive the training necessary
to conduct such assessments in a culturally appropriate manner. Indeed,
CSWE's (2008) Educational Policy and Accreditation Standards
underscore the importance of developing competence in the area of
assessment (Educational Policy, 2.1.10[b]).
In keeping with this aim, this study was conducted to identify
information designed to assist future practitioners in administering
spiritual assessments in a culturally competent manner with Native
clients. In other words, this qualitative study sought to answer the
question: How can future social workers conduct spiritual assessments
with Native clients in an effective, culturally competent manner? The
methods employed to answer this question are discussed in the following
The study sample consisted of individuals with specialized
knowledge of Native American culture (Pace et al., 2006). To identify
such individuals, a hybrid purposive/snowball sampling strategy was
used. One member of the research team is a Native American scholar with
extensive research and practice experience with Native populations. This
individual contacted a number of potential participants who are widely
recognized within the social work profession as having extensive
knowledge of Native American culture. In turn, these individuals were
asked to identify other experts. All correspondence was personalized in
keeping with research suggesting that this practice increases response
rates (Heerwegh, Vanhove, Matthijs, & Loosveldt, 2005).
Using this approach, 67 experts were identified. Of these, 50
agreed to participate in the study, yielding a 75% response rate. The
resulting sample is similar in size to previous, related research
(Weaver, 1999; Weaver, 2000). The average respondent was about 50 years
old, female, and had a social work degree (see Table 1). Study
participants exhibited a relatively wide range of tribal, geographic,
and spiritual affiliations, which enhances the validity of the study by
incorporating diverse perspectives. For example, the diverse regional
representation in this study helps to safeguard against any extant
Survey instrument. The present study was part of a larger project
designed to validate six qualitative spiritual assessment tools or
instruments for use with Native Americans. These tools consisted of a
brief assessment tool (Hodge, 2004), and five comprehensive instruments:
spiritual histories (Hodge, 2001a), spiritual life maps (Hodge, 2005a),
spiritual genograms (Hodge, 2001b), spiritual eco-maps (Hodge &
Williams, 2002), and spiritual ecograms (Hodge, 2005b). Drawing from the
concept of cultural or social validity, the larger project sought to
take assessment tools created for general use, assess their level of
consistency with Native American culture, and then adapt them for use
with Native American clients (Foster & Mash, 1999; Gresham &
Lopez, 1996; Lane & Frankenberger, 2004; Wolf, 1978).
The survey instrument described and illustrated each spiritual
assessment tool. One qualitative item explored each tool's
strengths from a Native American perspective. Similarly, another item
explored each tool's limitations in terms of its use with Native
Sample questions were provided to demonstrate how the assessment
tools are typically operationalized with members of the general public.
Respondents were then asked to identify ways in which various question
sets could be altered, modified, or changed to be more congruent with
Native culture (e.g., "How could these questions be improved to be
more valid, relevant, and consistent with Native American
The question sets varied from tool to tool, but collectively the
areas addressed included a diverse array of subjects related to
spirituality. These subjects included affect, cognition, the Creator or
God, communion with the Creator, conscience, intuition, faith
communities, family functioning, family history, rituals or ceremonies,
spiritual beings (e.g., angels), and volition. Thus, respondents were
asked to assess, from a Native perspective, a wide variety of content
directly related to the process of administering a spiritual assessment.
Procedures. After institutional review board approval was received
from each author's institution, the survey instrument was placed
online, and the URL link was e-mailed to individuals who agreed to
participate in the study. Individuals were concurrently informed that a
hard copy of the survey was available, although no one requested this
option. Some research suggests that response rates for paper and
Web-based surveys are comparable, and the data produced are generally
similar in content (Kaplowitz, Hadlock, & Levine, 2004). For
open-ended, text-based questions, some evidence suggests that Internet
surveys may yield longer answers, although further research is needed to
confirm this finding (Denscombe, 2006). In appreciation for their time,
respondents received a $50 honorarium for completing the survey.
Data analysis. Inductive and deductive analytic strategies were
employed to identify and relate pertinent data. In keeping with the
grounded theory tradition (Glaser & Strauss, 1967), an inductively
oriented, constant comparative methodology was used to examine responses
for similarities, patterns, and common concepts (Padgett, 2008). In a
recursive process, the data were continually compared to similar
phenomena across responses to identify, classify, and refine the
emerging themes (Dye, Schatz, Rosenberg, & Coleman, 2000).
Concurrently, a deductive approach was also used to organize,
relate, and synthesize the emerging themes into a coherent format
designed to answer the research question (Strauss & Corbin, 1998).
In preparation for this study, the researchers read widely across the
social work literature addressing spirituality and Native Americans,
with a particular emphasis upon content related to spiritual assessment.
In turn, this lens informed the construction of the resulting
categories. Each category contained either a single primary theme or a
family of closely related themes, and often sub-themes as well.
The data analysis yielded four data-driven categories, which serve
as subsections of the following section. Representative paraphrases
and/or quotes are used to illustrate the themes that emerged within each
category. The subsections are Importance of Assessment, Preassessment
Considerations, Conducting the Assessment, and Potential Value
Importance of Assessment
Spiritual assessment was perceived to play a critical role in
therapeutic success with Native clients. Various respondents noted that
assessment can facilitate relationships between practitioners and
clients, foster a more collaborative working relationship, and help
ensure positive outcomes by giving practitioners the tools to construct
interventions that resonate with clients' belief systems. A number
of these concepts are illustrated in the following comment:
Respondents also mentioned a number of issues that future
practitioners might consider prior to conducting spiritual assessments.
The primary theme in this subsection was the importance of developing
familiarity with common tribal beliefs and practices. As one respondent
observed, "Native cultures generally adopt a very different
worldview--different ideas about how things, actions, and people are
related." Consequently, it is important to develop a basic
understanding of the tribal worldviews commonly encountered in health
care settings. At least four reasons were offered to underscore the
importance of developing working conceptualizations prior to seeing
Rationales for understanding common tribal beliefs. First, because
of a number of historical factors, it is inappropriate to place clients
in a position where they are required to educate social workers about
their beliefs and values. As one respondent stated, "We have to be
careful that we are not asking clients to 'teach' the workers.
The workers need a good base of information about the population they
are to work with. Otherwise, the client will withdraw and not return for
Second, a basic understanding enables practitioners to ask
culturally appropriate questions that help practitioners understand
clients' phenomenological reality. As one expert noted, to work
effectively with clients, "the therapist must have the ability to
ask the right questions--to understand what questions are pertinent to
ask to make clear the teachings and assumptions of the client's
worldview." In other words, a working understanding of a culturally
different worldview enables one to ask the appropriate questions to
fully understand the client's unique circumstances.
A third reason is to avoid asking culturally inappropriate
questions. Knowledge of tribal cultures enables social workers to avoid
posing questions that are culturally taboo. As one respondent noted, if
such taboo questions are asked, "everything after that will be
affected. In some cases, the interview will be over, the respondent will
'disappear.' Perhaps forever."
A fourth reason is to address any issues stemming from a lack of
understanding regarding Native people's cultural history and
present challenges that may affect the therapeutic relationship. In
keeping with this line of thought, one respondent observed, "It is
my experience that far too many non-Native therapists simply do not
understand our historical and current experiences. Too often when they
begin to understand, 'White guilt,' 'defensiveness,'
etc. begin to emerge." Developing an understanding of Native
history before meeting clients enables one to work through biases and
emotional responses that may negatively influence service provision.
Extensions and qualifications regarding tribal belief systems.
Related to the theme of developing familiarity with tribal beliefs and
practices were two subthemes that might be referred to as (a) the
uniqueness of each tribal worldview and (b) the complexity of beliefs
that exists among Native clients. Regarding the first subtheme,
respondents emphasized that each tribe is characterized by a specific
set of beliefs and values. Although Native Americans tend to share
certain characteristics that serve to demarcate them as a group, under
this broader rubric each tribal community has its own framework through
which reality is understood. Consequently, experts held it is important
to understand these various worldviews, especially if they are
encountered on a regular basis.
Concurrently, the complexity of beliefs at the micro level was also
underscored. As one person explained, "The Native community is very
diverse in its spirituality, in part because of the influence of tribal
beliefs, pan-Indian beliefs, European influences, and secularism."
Individual clients may be shaped, in greater or lesser degrees, by any
one of these four factors, either separately or in some combination.
Thus, clients may be devout Catholics and participate in traditional
purification ceremonies as well. Similarly, they may also faithfully
attend churches from more than one denomination (e.g., Native American
church and Methodist church).
Thus, before undertaking an assessment, it is helpful to know that
"there are no universal assessments that can fit all tribes."
Rather, "each person is unique within their own unique tribe."
Ideally, experts recommended entering the assessment process with a
working knowledge of commonly encountered tribal belief systems, but
tailoring each assessment to meet the needs of individual clients. As
one respondent emphasized, "Individuals' and individual tribal
beliefs MUST be honored" if one hopes to administer an assessment
Conducting the Assessment
A number of themes emerged that were related to the process of
training students to conduct assessments. Among these were the
intertwined themes of client trust, the historical oppression of Native
American spirituality, and the personal nature of Native spirituality.
The development of trust was deemed essential to the administration of a
spiritual assessment. The importance of trust was accentuated if no
prior relationship existed with the client, and was held to be even more
critical if the practitioner was from outside the client's
Although trust is important in any cross-cultural encounter, it was
perceived to be particularly significant in the area of spirituality
because of the historical oppression of Native spirituality. As one
respondent stated, "Historically, Native people have had extremely
coercive experiences with organized religion and have, not long ago,
been punished for practicing their outlawed traditional religious
ceremonies." Similarly, another respondent observed, "Native
American spirituality has been feared, misunderstood, misconstrued, and
exploited for centuries by government officials, researchers, and the
general non-Native public."
In part because of this historical legacy, respondents emphasized
that spirituality is a highly sensitive topic for many Native clients.
The interrelated nature of these themes, and their potential
consequences, is captured by one individual who stated,
A number of strategies were offered to help practitioners address
this situation. As implied above, the time frames allocated to various
phases of the assessment process may differ for Native Americans
compared to the general population. As one individual stated, "The
engagement phase with Native Americans usually takes more time."
Thus, it was suggested that practitioners plan on devoting sufficient
time at the front end of the assessment process to develop trust and
rapport before proceeding with an assessment.
Another concrete step is the development of a context for
administering the assessment. More specifically, one might acknowledge
that spiritual beliefs and practices are very personal, explain why it
is necessary to gather spiritual information and how the information
will be used by the practitioner, clarify that one is free to refuse to
answer any or all questions, and proactively ask forgiveness for asking
questions that might be offensive. A respondent offered the following
comments to exemplify how a practitioner might go about creating the
proper context for conducting an assessment:
Other strategies involved the use of appropriate language and
phrasing. For instance, the use of nonacademic, easy-to-comprehend
language was recommended. As one respondent noted, "Many in our
Native communities have limited school or English as a second
Another theme was the importance of using language that normalizes
common Native beliefs. Suggestions in this area included using the words
ceremonies or customs rather than rituals. Similarly, Creator might be
used rather than God, or elder in place of mentor. The implied goal
cited by the respondents is to use terminology that implicitly
communicates respect for Native beliefs and willingness to work within
the parameters of a Native understanding of reality.
Within this context, the importance of guarding against assuming
that clients will hold particular belief systems was underscored. In
keeping with the diversity of beliefs noted above, some respondents
recommended adopting a neutral stance, phrasing questions in the most
nondirective way possible. As the client's belief system comes into
focus, practitioners can tailor their language to match that of the
Another theme concerned the adoption of a more relaxed,
conversational stance. The use of indirect questions, allowing more time
for clients to respond, and sharing relevant personal experience were
all mentioned. As one respondent emphasized, "Native clients should
not be 'probed,' ... [rather] story telling and waiting for a
shared response is more effective, being client led rather than
practitioner led." Another respondent encouraged practitioners to
"focus on simplicity, narrative, letting people tell their
stories," stressing that asking lots of questions was often
perceived as disrespectful in light of the fact that many European
Americans have misused Native spirituality for their own perceived
Finally, concern was expressed regarding practitioners' level
of competency to conduct a spiritually sensitive assessment. It was
noted that one must have the necessary skills and training to be able to
explore diverse expressions of spirituality in a supportive, open-minded
manner while eschewing inappropriate nonverbal reactions, including any
sign of impatience with silence--reactions that can effectively end the
assessment. Many of these concerns were captured in the following
Potential Value Conflicts
Potential value conflicts--often stemming from differences between
Native and secular value systems--was the final category produced by
analysis. One theme that emerged in this area is the lack of separation
between spirituality and the rest of life. Members of the dominant
culture were perceived to compartmentalize spirituality in a sphere
separate from the material, whereas Native Americans were viewed as
holding a more holistic understanding of reality. As one individual
noted, "For many tribal cultures, spirituality is interwoven
throughout all of life. Separating out spirituality may be problematic
or impossible." Another stated, "Some native peoples do not
see themselves as separate from their spirituality, connectiveness to
the Creator. My belief system is me as I exist. Religion is our way of
life, not a separate entity of myself."
Another area of potential conflict is the exploration of secret or
taboo areas. Although the discussion of spiritual beliefs and practices
is generally accepted in the dominant culture--at least to some
degree--experts noted the discussion of specific beliefs and practices
is prohibited in many Native cultures. As one respondent stated,
"For some traditional people, discussing beliefs beyond an initial
one or two word identification is taboo, especially with [cultural]
Ceremonies, spirit beings, and talking about those who have passed
on are among the areas in which practitioners were encouraged to be
cautious. In addition to the concern that ceremonies will once again be
misappropriated, respondents highlighted the importance of knowing that
many Native ceremonies are secret and can only be shared within certain
tribal circles. In many Native tribes, talking about or drawing symbols
of spirit beings is prohibited. Similarly, other respondents noted that
some Native traditions dictate that one never talks about those who have
passed on, including never asking questions about them.
In many cases, the sensitive nature of these topics was linked to
the holistic, integrated worldview mentioned above. For instance, one
In keeping with the linkage between spiritual and physical realms,
sharing taboo information with others, it was observed, can result in
the perpetration of harm. Many ceremonies, for instance, are seen as
"very powerful things that draw the spirits, good and bad.
Similarly, asking about evil spirits may invite them to come back.
Speaking the names of or speaking about those who have passed on can
result in people being cursed or put in jeopardy.
Consequently, discussing such issues is often perceived as
profoundly disrespectful and can result in clients' terminating
services. In a widely echoed observation, one person stated, "In
some cases, simple inquiry into these zones will effectively shut down
the interview for all valid purposes." Although it was recognized
that practitioners may have legitimate reasons to explore these areas in
light of the linkage between many practices and wellness, respondents
emphasized the importance of implementing procedures to make clients
feel comfortable opting out of certain discussions.
In circumstances that called for the tentative exploration of
sensitive areas, a number of suggestions were offered. At a foundational
level establishing good rapport, recognizing the sensitive nature of the
topic, and requesting permission to address the area before proceeding
were mentioned. These principles were operationalized in various ways by
respondents. Some slightly paraphrased options included asking: Although
you may not be able to share the details of a ceremony, are there some
ceremonies that help you cope with difficulties? and Are you able to
describe any ceremonies that you use to deal with these experiences?
Another alternative is to use open-ended, implicit questions that do not
explicitly address potentially private matters or call for a direct
response but leave the option of how to respond with the client. A
different approach is to have the client think about the ceremonies
without sharing them and then explore ways the client can be linked with
the appropriate services.
Another potential value conflict that emerged related to the area
of cognitive training or thinking patterns. Practitioners were perceived
to have been schooled in a milieu that values linear methodologies,
whereas Native cultures tend to favor more circular processes.
Respondents suggested this latter way of being translates into a
relative emphasis upon the use of more indirect, implicit questions,
allowing time to fully describe events, the use of circular models such
as the medicine wheel and frameworks that stress the interconnection of
The relative importance of written texts in the two cultures was
also cited as an area of potential concern. Respondents noted that
written texts often carry less stature in Native cultures. In contrast
to the more textually oriented European culture, Native tribes tend to
vest authority in oral tradition. As one respondent stated, "We are
a storytelling people." Consequently, some suggested that
pen-and-paper assessment instruments filled out by clients may be
inconsistent with some Native cultures. A more culturally consistent
medium may be verbally based approaches in which clients are asked to
share their stories. Similarly, some visually based, diagrammatic
approaches that incorporate the use of a variety of senses were also
perceived to represent a good fit for many clients.
What constitutes a family is another area in which potential
conflicts may emerge. As one respondent stated, "Many traditional
Native people do not actually function within many people's notions
of the nuclear family. Family, clan relationships can be extremely
complex." Consequently, instruments such as spiritual genograms may
have limited utility with many of these clients because of the
complexity entailed in diagramming very complicated family structures.
It was observed that this extended family structure also often plays an
instrumental role in supporting Native clients in times of crisis, along
with church clans, family members, tribal communities, governmental
agencies, and other environmental resources.
Another theme that emerged is differential emotional reactions and
values because of the legacy of historical trauma and oppression. The
potential conflicts in this area were captured by one individual who
noted, "Some of us are rightfully angry about elements in our
environment and history and societies and cultures. Our notions of
'right and wrong' might be at least somewhat unusual to some
therapists." For instance, in some cases, children were beaten in
religious schools and told not to practice traditional religions.
Questions that touch on these memories may elicit considerable pain,
which practitioners, it was noted, must be prepared to deal with
Assessment is one of the core competencies specified in CSWE's
(2008) Educational Policy and Accreditation Standards (Educational
Policy, 2.1.10[b]). This study may be the first empirical research
designed to assist future social workers in administering spiritual
assessments with Native American clients in an effective, culturally
competent manner. As such, this study adds to the limited empirical
knowledge base on culturally competent practice with Native Americans
(Weaver, 1999; Weaver, 2000).
Although electives on spirituality and religion are increasingly
common (Canda, 2005), the results underscore the importance of
incorporating educational content on spirituality and religion
vertically and horizontally into required graduate curricula. The
findings simultaneously underscore the importance of spiritual
assessment while raising concerns about the ability of practitioners to
conduct these assessments appropriately. Such concerns are likely
warranted because--as noted at the beginning of this article--most
social work students and practitioners report receiving minimal training
in spirituality during their graduate educations (Canda & Furman,
2010; Carlson, Kirkpatrick, Hecker, & Killmer, 2002; Heyman,
Buchanan, Musgrave, & Menz, 2006; Murdock, 2005; Sheridan, 2009;
Sheridan & Amato-von Hemert, 1999).
Consequently, it is critical that all students receive the training
necessary to interact with Native American spirituality in an ethical
and professional manner. Without the necessary training to inform
practitioners' actions, culturally insensitive assessments are
perhaps inevitable. As the findings suggest, such assessments can
effectively terminate the helping process. The fact that social workers
may be required to conduct assessments in Joint Commission-accredited
settings serves to accentuate the need for training across the
curriculum (Hodge, 2006; Koenig, 2007).
Practice courses are perhaps the most obvious setting in which to
address the issues raised in this study. Although various definitions of
cultural competency exist, it is often conceptualized as an intertwined
set of attitudes, skills, and knowledge (CSWE, 2008; Hodge &
Bushfield, 2006; NASW, 2001; Sue & Sue, 2008). In the context of
training students in these attributes in practice courses, content
related to Native Americans can be integrated into the curriculum.
For instance, traditional assessment content might be supplemented
with an examination of various approaches to spiritual assessment (Canda
& Furman, 2010; Derezotes, 2006; Hodge & Limb, in press-a).
Educators might discuss the various options that exist in terms of their
degree of congruency with Native culture. Particular attention might be
devoted to approaches that have been validated with Native Americans,
including brief assessment tools (Hodge & Limb, in press-b), and
comprehensive tools such as spiritual histories (Hodge & Limb,
2009a), spiritual lifemaps (Limb & Hodge, 2007), spiritual genograms
(Limb & Hodge, 2010), spiritual ecomaps (Hodge & Limb, 2009b),
and spiritual ecograms (Limb & Hodge, in press).
To develop competency in assessment, educators might consider
having students form dyads and then practice administering spiritual
assessments using different approaches. After conducting an assessment
with a given approach, student dyads might debrief with one another.
Individual dyads might be asked to provide a list of things that did and
did not go well during the assessment. After a set period of time, all
the student dyads could meet, and the educator could facilitate a group
discussion while highlighting issues that are particularly relevant to
work with Native Americans. For example, educators might alert students
to common Native proscriptions regarding those who have passed on after
students have practiced administering spiritual genograms (Frame, 2003).
Similarly, when discussing transference and countertransference,
the issue of spiritual countertransference might be discussed as it
intersects work with Native clients (Genia, 2000; Hodge, 2003; Napoli,
1999). Students might be encouraged to begin the process of working
through issues that may hinder their ability to respond in a
client-centered manner. Potential value conflicts between Native and
secular worldviews might be examined in self-reflective homework
Content on referral is another area that might be emphasized in the
direct practice curricula. The attitudes, skills, and knowledge
necessary for culturally competent practice exist on a continuum (Hodge
& Bushfield, 2006; Sue & Sue, 2008). Given the sensitive role
that spirituality typically plays in Native cultures, it is critical
that students learn to consider their capabilities in light of the
various tribal members they are likely to encounter (Reamer, 2006).
Educators might facilitate discussions about the advisability of
referral in various contexts, networking with practitioners skilled with
various tribal populations, and other options to enhance the provision
of effective culturally sensitive services.
Agency culture is another issue educators might examine with
students (Canda & Furman, 2010). Students should be encouraged to
assess an agency's openness to accommodating spiritual-health
linkages that deviate from accepted secular practices. Although
accrediting requirements are helping to change the organizational
culture in many settings, not all agencies are open to treatment plans
that incorporate client spirituality. There is little point in
conducting an assessment, developing a mutually agreed-upon treatment
plan, and engendering clients' hope that their spirituality will be
integrated into therapy only to find that the organization will not
support treatment plans that incorporate Native spirituality. In such
situations, referral may be an option along with hybrid plans that
incorporate client spirituality in other nonagency settings.
In addition to practice courses, diversity and policy courses might
also benefit from incorporating a Native perspective. In diversity
courses, students might be encouraged to present PowerPoint
presentations on the beliefs, practices, and cultural norms of Native
American tribes, especially those in the catchment area served by a
given social work program. Students might be asked to structure such
presentations to highlight content that is particularly relevant to the
engagement and assessment process. In addition, either diversity or
policy courses might include content on the history of Native Americans
in the United States, which can help students understand reality through
a Native lens.
Policy courses might also include content on legislative
initiatives designed to safeguard Native expressions of spirituality,
such as the American Indian Religious Freedom Act (AIRFA, 1996). AIRFA
protects Native Americans' right to religious freedom, including
their right to believe, express, and exercise their traditional
religions. The law addresses such issues as access to sacred sites, use
and possession of sacred objects, and freedom to worship through
ceremonies and traditional rites. Such material supplements content in
practice courses by, for example, helping students understand and
advocate for clients' spiritual rights under U.S. law.
The results and discussion should be considered in light of the
study's limitations. Generalizing the results beyond the present
sample is precluded by the nonprobability sampling methodology. Further,
the relatively small sample size in relation to the number of Native
tribes should also be considered a limitation. Concurrently; the
sampling strategy is appropriate given the relatively small number of
experts in Native culture, and as noted before, the sample is similar in
size to previous related research (Babbie, 2007; Weaver, 1999; Weaver
The coding of data from questions not originally designed to
directly answer the study's research question may also interject
some degree of bias into the findings (Tsang, 2001). Although some
information on culturally competent assessment is reported in the
validation studies of each instrument (e.g., Limb & Hodge, 2007),
space constraints precluded a full examination of all the relevant data.
Hence, this study was conducted to identify all information that might
assist future social workers in conducting spiritual assessments in a
culturally competent manner.
Educational programs play an indispensable role in equipping the
next generation of practitioners to provide effective services to
disenfranchised populations (Drake, Jonson-Reid, Hovmand, & Mayas,
2007). The health disparities Native Americans experience are well
documented (Beals et al., 2005; Castor et al., 2006; Harris et al.,
2005; Villanueva, Tonigan, & Miller, 2007). Although eliminating
health disparities is a federal goal realizing this aim with traditional
secular approaches most social workers have traditionally been schooled
in may be difficult. As Gone (2007) suggests, traditional secular models
of service provision are often seen as ineffective, oppressive, and even
pathologic by many tribal members.
Alternatively, spirituality is widely perceived to play a positive,
instrumental role in overcoming health-related challenges (Cross, 2001;
Napoli, 1999; Weaver, 2002). Spiritual assessment plays a foundational
role in identifying and operationalizing these spiritual assets. As
implicitly recognized in Educational Policy 2.2.10(a-d) in CSWE's
(2008) Educational Policy and Accreditation Standards, it provides the
necessary information to identify and implement effective practice
strategies (Gesino, 2001; Gone, 2007). This study helps future
practitioners administer these foundational assessments in a culturally
competent manner. As such, it assists social work educators to provide
more effective professional services to Native clients.
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David R. Hodge
Arizona State University
Gordon E. Limb
Brigham Young University
David R. Hodge is assistant professor at Arizona State University
and senior nonresident fellow at the Program for Research on Religion
and Urban Civil Society, University of Pennsylvania. Gordon E. Limb is
associate professor and director of the School of Social Work at Brigham
Address correspondence to David R. Hodge, Mail Code 3251, 4701 W.
Thunderbird Rd., Glendale, AZ 85306-4908.
With Native Americans--because spirituality
is so linked to Indian identity--it
is critical that a practitioner understand
as soon as possible what traditional
beliefs are relevant to that person
in order to tailor a treatment plan
that the person will trust and follow.
This will help overcome the inherent
skepticism many Natives have of European
style health care approaches.
Spirituality is a very personal thing for
most people that are of Native cultural
backgrounds. Assessments should also
be based in a relationship of trust,
which takes time to build. Even asking
about a "denomination" can create
barriers in the relationship or lead a
Native person to think that the practitioner
expects them to have a denomination.
This could shut down the relationship
for a traditional person.
It used to be social workers or healthcare
providers did not really understand
or appreciate the importance of
spirituality and religion in supporting
an individual's health and wellness.
Today, there is greater respect for the
role of spirituality and religion in supporting
a person's well-being and even
the well-being of his or her family and
community. Because of this new sense
of respect and understanding, I'd like
to ask you a few questions. Of course,
you are free to not answer any that you
don't feel comfortable answering or
you feel are too personal. We can always
discuss any of these things later.
Even if tribal participants [i.e., clients]
are able to describe their beliefs and
practices in response to non-directive,
non-biased questions, understanding
depends on the person who is conducting
the assessment. Does the interviewer
share a 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 more importantly, will this
experience be based on partnership
between the interviewer and the participant?
Will this approach result in greater
self-esteem and self-determination for
participants? A focus on internal and
environmental strengths and vision for
I know among some of our people--they
don't use the term death or dead
but rather no longer with us (physically)
or gone away. This is because the idea
that b/c [sic] someone is not physically
here they are actually spiritually here.
TABLE 1. Demographic Characteristics of Native American Experts
Characteristic M SD N %
Age 49.92 11.71
Female 32 64.0
Male 18 36.0
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