Promises and Perils of Spiritual care
assessment: with special references to
religious/cultural perspectives
Philip Crowell, PhD, MA, MDiv.
Chaplain and Director, BC
Children’s and Women’s Hospitals,
Vancouver, BC
Promises & Perils
 The reality - we need to do it…
 Great benefit when it is done right
 The need for competency in order to
do it appropriately
 Assessment, interpretation,
evaluation, measurement is part of
our culture with respect to another
person/family and their culture
The Art of Spiritual Assessment
 Is there an art, science and skill involved
that goes beyond the assessment
questions?
 The value of the inner wisdom and selfawareness of the assessor?
 How important is the arete, skill, virtue and
competency of the assessor and
interpreter? The art of questions….
 What do we see when we enter a hospital
room?
From Illness and Healing: Images of Cancer –
by Robert Pope
 “Cancer in older people carries with it
a tacit acknowledgement of
inevitability, but in children we are
surprised, and uncomprehending.”
 “In this drawing, Erica, with hair gone
from the treatments, touches the
pump that administers her
chemotherapy.”
Perils and Promises:
In using tools we are able to take a
measure at a moment in time
 A toolkit of supplies – JPCC vol. 59,nos 12 Spring-Summer, 2005, Thomas
St.James O’Connor, Kathleen O’Neill, Grace
Van Staalduinen, Elizabeth Meakes, Carol
Penner, and Katherine Davis, “Not Well
Known, Used Little and Needed: Canadian
Chaplains’ Experiences of Published
Spiritual Assessment Tools”
Tools
Spiritual Assessment Tools
Religious Attitude Inventory
 W.E. Broen, “Personality Correlates of
Certain Religious Attitudes, “Journal of
 Consulting Psychology, 1955, vol. 19, p.
23; David Foy, James D. Lowe, Lee K.
Hildman, & Keith Jacobs, “Reliablity,
Validity and Factor Analysis of the Religious
Attitude Inventory” Southern Journal of
Educational Research, 1976, Vol 10, pp.
235-241.
tools
 Gordon Allport and James Ross, “Personal
Religious Orientation and Prejudice,” Journal
of Personality and Social Psychology, 1967,
Vol. 5, pp. 432-443;
 Michael J. Donahue, “Intrinsic and Extrinsic
Religiousness: The Empirical Research,”
Journal for the Scientific Study of Religion,
1985, Vol. 24, pp. 418-423. Ralph W. Hood,
“The Conceptualization of Religious Purity in
Allport’s Typology, “Journal for the Scientific
Study of Religion, 1985, vol. 24, pp. 413417;
And even more tools
 R.W. Hood, “The Construction and
Preliminary Validation of a Measure of
Reported Mystical Experience,”
Journal for the Scientific Study of
Religion, 1975, Vol. 14, pp. 29-41.
The last of the tools…. There will be
more
 C. Daniel Batson, “Religion as Prosocial: Agent or
Double Agent,” Journal for the Scientific Study of
Religion, 1976, Vol. 15, pp. 29-45.
 Keith Edwards, “Religious Experience Questionnaire,”
Dissertation Abstracts International, 1976, Vol. 36.
The God Questionnaire
 Anna-Maria Rizzuto, The Birth of the Living God: A
Psychoanalytic Study (Chicago, ILL: The University of
Chicago, 1979).
Fitchett
7x7 Model of Spiritual Assessment
 George Fitchett, Assessing Spiritual Needs: A Guide
for Caregivers (Minneapolis, MN: Augsberg Fortress
Press, 1993); also see, G. Fitchett and J. Russell
Burch, “A Multi-Dimensional Functional Model for
Spiritual Assessment,” The Caregiver Journal, 1990,
vol. 7, pp. 43-62.
Mental, Physical and Spiritual Well-Being Scale
 Dianne Vella-Brodrick and Felicity Allen,
“Development and Psychometric Validation of the
Mental, Physical, and Spiritual Well-Being Scale,”
Psychological Reports, 1995, Vol. 77, pp. 659-674.
Assessment and interpretation
Spiritual Self-Assessment Form
 Lyn Brakeman, “Theology as a Diagnostic Tool in
Assessing Spiritual Health,” The Journal of Pastoral Care,
1995, Vol. 49, pp. 29-38.
Spiritual Assessment Inventory
 Todd Hall and Keith Edwards, “The Initial Development
and Factor Analysis of the Spiritual Assessment
Inventory,” Journal of Psychology and Theology, 1996,
Vol. 24, pp. 233-246; Todd Hall and Keith Edwards, “The
Spiritual Assessment Inventory: A Theistic Model and
Measure for Assessing Spiritual Development,” Journal
for the Scientific Story of Religion, 2002, Vol. 41, pp.
341-357.
Spiritual assessment 1: Fitchett
 Problems with a medical model
 Assessment is both a statement of
perception and a process of information
gathering and interpreting.
 “I use the term assessment as a noun and
a verb. Because it is both process and
content, it is inherently a dynamic
concept.” George Fitchett, Assessing
Spiritual Needs, p,17
Continued - 2
 Multi-focused assessments are often guided
by questions such as: what does this
person want?
 What do I think he needs? Do I feel
qualified to help her?
 What kind of help is expected or required of
me in the institutional context of this
assessment (compare the patient’s hospital
room and the parish pastor’s office)?
Assessment -3
 What are the likely consequences if I elect
to do more or to do less than expected?
 What other departments or services will
also be involved in the patient’s care?
 What additional resources will be need to
help this person or to help me help him?
 Are those resources available? If not, is it
better to postpone any intervention until
they are?
Assessment 4
 When is the best time to make an
assessment?
 A chaplain in Fitchett’s survey was careful
not to make an assessment until he had
gotten to know a patient, during a second
visit at the earliest.
 However, one sizes up a situation as soon
as you enter a room, i.e., “am I welcome
here today or not?”
Spiritual Care/Pastoral Counselling
Core Competencies
January 2010 / March 2010
 This document is a first attempt to summarize the
core competencies (knowledge, skills, attitudes,
behaviours) that are required for the practice of
Spiritual Care/Pastoral Counselling. These
competencies can be observed, demonstrated,
evaluated and assessed.
 The following nine competency categories were
derived from the National Validation Survey (2008)
which included competencies identified through the
DACUM project (2006). The actual competency
statements validated through the survey are grouped
under these main categories.
“A top ten list”
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Spiritual Assessment
Self-Awareness
Spiritual and Personal Development
Multi-dimensional Communication
Brokering Diversity
Ethical Behaviour
Collaboration & Partnerships
Facilitating Learning
Leadership
Research
Spiritual Assessment (includes the development of care plan,
implementation and evaluation of outcomes)
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A.4 Create spiritual care plan.1
B.2 Utilize evidence-based practice.3
B.4 Identify person's sense of purpose1
B.5 Help person evaluate role and function of
spiritual religious identity in their life.1
B.7 Invite clients to draw upon their spiritual
and religious resources.1
B.10 Employ a variety of intervention techniques
to achieve care plan goals (or therapy goals and
objectives).1
B.12 Engage in reflection and dialogue on
spiritual issues of significance to the client.1
B.13 Allow client to tell his / her story as a way
to seek for meaning / purpose.1
Continued -Compiled by Becky Vink, January 11,
2010
Modified by Margaret Clark, March 1, 2010
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B.14 Engage with client's experiences of (trauma,
distress) pain, suffering and dying.1
B.15 Acknowledge the sacred in human experience.1
B.16 Assist persons in their own creative expression
of spirituality.1
B.17 Offer guidance for spiritual growth.4
B.18 Engage in prayer where appropriate.4
B.19 Enable reconciliation (e.g. conflict management
forgiveness, relationship).5
B.20 Provide and facilitate rituals, rites and
ceremonies.2
B.24 Function as primary therapist / clinician /
spiritual counsellor as required.3
E.1 Assess the dynamics of the culture, resources and
community.3
Assessment on assessment 5
 In medicine, the patient has an
admitting diagnosis, a subsequent
assessment confirmed or revised
diagnosis/ assessment that guides
the therapy
 For example, In DSM IV the diagnosis
of Schizophrenia requires that
continuous signs of the illness have
been present for at least six months.
Assessment 6 – “over-time”
 In psychoanalytic treatment of
narcissistic personality or behavior
disorders, according to H. Kohut, it is
necessary to wait to see if one of the
characteristic narcissistic
transferences develops before one
makes a definitive diagnosis.
Importance of spiritual assessment
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Foundation for action
Foundation for communication
Foundation for contracting
Foundation for evaluation
Foundation for personal accountability
Foundation for quality assurance
Foundation for research
Assessment as the touchstone for
profession’s identity
7 X 7 Model for Spiritual
Assessment - assumptions
 Each of us is a whole person
 Our spirits are not separate from our
bodies, our emotions, and our
thoughts
 There are two major divisions and 7
dimensions within each
Holistic Dimensions -7
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Medical context dimensions
Psychological state dimensions
Psychosocial dimension
Family system dimensions
Ethnic and cultural dimensions
Societal issues dimensions
Spiritual dimensions
The Spiritual Dimensions (7pts)
1. Beliefs and Meaning- stories – religious
symbols – literal, broken myth, and
restored myth – noting the inconsistencies
of the stories – meaning from caring for
others – for her husband
2. Vocation and consequences – duties called
to fulfill – able to fulfill? Impasse?
3. Experience and Emotion – what experiences
of peace in life have been experience? Or
joy?
Spiritual dimension – 7 x 7
4. Courage and Growth – courage to be – to
enter the dark night of the soul – “living
wake” – the possibility of new beliefs? Has
growth been slow or sudden?
5. Ritual and Practice
6. Community – RC parish, her partner – is
the community as resource for the patient?
7. Authority and Guidance – will the patient
allow the chaplain to help, support, and
offer guidance when struggling?
A case – Mrs. Gabatino
 facing her own death and cancer
 Reflecting on her faith, partner, the
death of an infant - SIDs, no other
children, 7 foster children, Italian
background,
 Anxiety absent, grateful, joyful,
angry, exhausted, timid, worthless,
and guilty.
What is our approach in contrast to
genetic counseling assessment?
 Genetic testing and information often raises
issues that are existential, having to do
with illness, suffering, loss, choices and
death
 Spiritual and religious values will influence
how some people respond to genetic
information
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(“Religious and Spiritual Concerns in Genetic Testing and
Decision Making: An Introduction for Pastoral and Genetic
Counselors” Journal of Clinical Ethics, Summer 2006)
Ethical decisions
 They may reconsider their feelings about
being induced or abortion and worry about
how their family, friends, and religious
communities may react
 Spectrum- from anacephaly to trisomy 21
 They may worry about what the future
might bring for the child, knowing that life,
at some level, is always a struggle, but
harder for those who are disabled
Genetic and spiritual care
counselors
 Can be a tremendous help to parents
grappling with these questions.
 Help identify their social, psychological and
spiritual resources
 Seek to dispel any misperceptions about
the cause or effects of a genetic
abnormality and minimize negative thought
patterns (blame/guilt)
The basics
 assessing various traumatic
situations so we can respond
 Spiritual care may include the ability
to make a spiritual assessment and to
follow up - and/or to conduct rituals,
helping people to draw on the
positive elements of their faithbeliefs, or rituals of lament/sorrow
Integration
 Park Ridge Center for Health, Faith
and Ethics (2004) study encourages
genetic counselors to learn about
different religious frameworks and
language to effectively assess
patients’ spiritual needs
 Caution about any directive
counseling – assessing other
counselors involved
 Will some want guidance and
affirmation?
The Balance
 the danger of stereo-typing vs. not
knowing their basic cultural/religious
assumptions
 What to ask? The same questions
will mean very different things to
different individuals because of their
cultural lens
The spiritual/ethical questions in context:
E.o.L. settings, inductions, palliative care
 What is a good life? What is our
responsibility to limit human suffering? To
allow natural death? To have a D.N.A.R.?
 What is the place of hope?
 Will it be better to be born then not to be
born? Will I be the same person if I make
a termination decision? What will it be like,
since I have never experienced a loss or
death of someone close?
Our questions
 Do you have the time, or skills to assess
and attend to their spiritual needs?
 The perils and the possibilities of spiritual
care “triage”
A consultation - assessment
 The Case: newborn, rare genetic
condition, respiratory failure, “softbones”, constrictive ribs, heartsurgery necessary, resuscitation
 2 months later – H1N1
 Aboriginal family, Catholic and
traditional way
 Modes of communication
Pediatric case
 Perinatal diagnosis – 8 months pregnancy
 Large mass discovered on the throat of
baby
 1) wait delivery and immediate surgery –
risk of oxygen debt
 (2) wait delivery and go palliative
 (3) ‘exit surgery’
 The couple not religious but spiritual with
background in the UCC.
Spiritual Assessment in Genetic
Counseling
 Journal of Genetic Counseling, vol.16, No. 1
Feb. 2007
 60% in a group of 127 genetic counselors,
reported they had performed a spiritual
assessment within the past year, however,
8% of these counselors assessed
spirituality in more than half of their
sessions
Barriers to spiritual assessment
 Lack of time, insufficient skills,
uncertainty regarding the role of
spiritual assessment within genetic
counseling
 This study suggests a need for
increased training regarding the
methods for and relevance of spiritual
assessment in g.c.
Back to holistic care
 Harold Koenig stated, “neglecting the
spiritual dimension is just like
ignoring a patient’s social
environment or psychological state,
and results in failure to treat the
whole person.” (2002, p.6)
Spirituality in Patient Care, by Harold
Koenig, p. 44)
Single Question Spiritual History:
“Do you have any spiritual needs or
concerns related to your health?”
Fear and Hope
 “The suffering human being needs a
place where he/she can rest, a place
which breathes genuine hospitality,
where fear and hope are permitted to
exist side by side… a place where the
naked face appeals for compassion
and finds response.” (Eriksson &
Lindstrom, 2003)