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Conducting spiritual assessments with Native Americans: enhancing cultural competency in social work practice courses.
Abstract:
Developing competency in diversity and assessment are key educational priorities. With Native American clients a spiritual assessment is typically required because spirituality is often instrumental to health and wellness in Native cultures. In keeping with the movement toward competency-based education, this qualitative study sought to answer the question: How can future social workers conduct spiritual assessments with Native American clients in an effective, culturally competent manner? Analysis yielded a number of practice-oriented insights that can be grouped into 4 categories: the importance of spiritual assessment, preassessment considerations, the process of conducting the assessment, and areas of potential value conflict. The implications of the results are discussed as they intersect social work education and practice courses in particular.

Article Type:
Report
Subject:
Native Americans (Social aspects)
Native Americans (Religious aspects)
Spirituality (Evaluation)
Social case work (Practice)
Social work education (Methods)
Authors:
Hodge, David R.
Limb, Gordon E.
Pub Date:
03/22/2010
Publication:
Name: Journal of Social Work Education Publisher: Council On Social Work Education Audience: Academic; Professional Format: Magazine/Journal Subject: Education; Sociology and social work Copyright: COPYRIGHT 2010 Council On Social Work Education ISSN: 1043-7797
Issue:
Date: Spring-Summer, 2010 Source Volume: 46 Source Issue: 2
Topic:
Event Code: 290 Public affairs; 200 Management dynamics
Geographic:
Geographic Scope: United States Geographic Code: 1USA United States
Accession Number:
229301878
Full Text:
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 section.

Method

Participants

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 geographic bias.

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 American clients.

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 culture?").

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 Conflicts.

Results

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:

Preassessment Considerations

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 Native clients.

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 services."

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 successfully.

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 community.

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 language."

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 client.

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 benefit.

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 comment:

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] outsiders."

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 individual commented,

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 entities.

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 appropriately.

Discussion

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 assignments.

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.

Limitations

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 2000).

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.

Conclusion

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.

DOI: 10.5175/JSWE.2010.200800084

Accepted: 10/09

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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 Young University.

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
   the future?


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
(IVC50)

Characteristic                        M      SD     N     %

Age                                 49.92   11.71
Gender
  Female                                            32   64.0
  Male                                              18   36.0
Tribal nation
  Lakota                                             4    8.0
  Navajo/Dine                                        4    8.0
  Chippewa / Ojibwa                                  6   12.0
  Cherokee                                           5   10.0
  Other tribal affiliation                          17   34.0
  Mixed blood/ American Indian                       6   12.0
  Non-Native                                         8   16.0
Area currently residing
  Northwest                                          7   14.0
  Southwest                                          9   18.0
  West                                              14   28.0
  Midwest                                           14   28.0
  East                                               6   12.0
Spiritual/ religious affiliation
Traditional (Native)                                22   44.0
  Christian                                         17   34.0
  Other                                              9   18.0
  None                                               2    4.0
Years of professional experience    16.97   10.21
Social work degree (yes)                            45   90.0
  Years in social work (n=45)       18.00    9.97
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