In sickness and in health: Including the spiritual domain as an aspect of psychological assessment

In recent times there have been calls for health professionals to take a more holistic approach to client care, one that considers the spiritual domain of human experience. In response, the spirituality-psychological health link is increasingly being explored in research (e.g., Proctor et al., in review a/b). Clinically and therapeutically, the spiritual needs and experiences of clients are being increasingly considered when planning protocols of care, especially in the areas of serious and life-threatening illness, death and bereavement (e.g., Anderson et al., 2005; Plante & Sherman, 2001).

Defining spirituality

One challenge faced by psychologists wanting to include spirituality in their psychological practice is to decide what is meant by the term ‘spirituality', including identifying how spirituality differs from religion. While there are many defintions in the literature, the following description distinguishes between spirituality and religion and does not solely confine spirituality to the domain of formalised religious traditions. Spirituality involves a "search for the sacred", whereas religion involves a "search for the sacred" which "must be done in the context of a group that legitimizes its means and methods"(Slater et al., 2001, p.5). Most contemporary definitions of spirituality conceptualise the construct as multi-dimensional (Paloutzian & Park, 2005) and "necessarily include: the subjective feelings, thoughts and behaviors that arise from the search for the sacred" (McMinn & Hall, 2000, p.252).

Avoidance of the spiritual domain

Working with clients who experience and (re)interpret health and illness (physical and/or psychological) from within a particular spiritual paradigm or world view can be challenging. Research with health professionals has revealed a number of reasons why they may avoid the spiritual domain, which has been summarised by Proctor and Mclean (in press) as follows.

• Lack of relevance of spirituality to human experience
  - e.g., they are personally unaffiliated to any spiritual tradition or have no spiritual orientation, or do not appreciate why inclusion of the spiritual domain is important to some clients.
• Perception that spirituality lies outside the domain of health care
  - e.g., they believe it is the domain of theologians, ministers and pastoral care workers, or they are unwilling to accommodate the spiritual dimension within health care planning and delivery.
• Not appropriately skilled to deal with spirituality-related health issues
  - Theoretically - e.g., they feel inadequately educated about spirituality, or have a limited understanding of spiritual issues as they relate to health.
  - Assessment-wise - e.g., they believe specialised training is required to administer assessment tools, lack confidence to assess spirituality, are unclear/unaware of appropriate assessment tools, or are unclear how to interpret assessment findings.
  - Clinically - e.g., they lack confidence to discuss spirituality with clients, are unclear how to open a conversation about spirituality, or feel ill equipped to provide appropriate spiritual support and/or to address spiritual distress.

Why the spiritual domain should be considered in clinical practice and research

The spiritual domain should be included primarily because it is a matter of respect and relevance. During significant life events (e.g., grief, crisis, etc), individuals often turn or return to spirituality, even though it might not have been a formative part of their life. Research is revealing that clients are increasingly expecting health professionals will deal with their spiritual concerns, especially at these times (e.g., Sperry, 2003). The quality of the therapeutic relationship may be enhanced if clients experience psychologists as having regard for the ways in which spirituality informs how they manage their lives, including their health. An understanding of the spiritual domain may provide important information with implications for treatment protocols (e.g., providing spiritual care to a dying patient), or may reveal additional support mechanisms able to be mobilised to facilitate a resolution to the immediate problem. It may provide some insight into how and when the client uses specifically spiritual coping strategies, and whether such strategies have proved useful and successful in resolving prior issues and in coping with challenging personal life experiences.

Professionally and ethically, psychologists are obligated to consider the spiritual domain and respect the values and beliefs that guide clients' lives. Professional guidelines and some government and public health policies require that the spiritual domain be included as part of a holistic approach to healthcare. In the event a psychologist does not feel skilled to manage this aspect of care, the client should be referred on to another appropriately qualified psychologist. Professional development can provide one avenue to up-skill practitioners in the area of psycho-spirituality so that clients with spiritual world views and issues can be effectively assisted.

Assessing spirituality

Evidence is now emerging that the therapeutic context and relationship can provide a safe and secure place, and a key dyadic relationship in which individuals might report, explore, review and explicate the (sometimes defining) role of spirituality in their lives. Taking a spiritual history and using appropriate spiritual assessment tools can enable information to be gathered about spirituality relative to the nature of the presenting problem. Issues such as the client's religious coping style (e.g., active or passive), religious orientation (e.g., intrinsic, where spirituality is an end in itself, or extrinsic, where spirituality is a means to a personal or social end), beliefs about divine intervention, and spiritual behaviour and practices (e.g., attendance at church, frequency of prayer, participation in spiritual community etc) can be assessed. An understanding of childhood and adolescent religious socialisation can further assist in exploring how early beliefs have influenced a client's life and decision making.

A full spiritual assessment is not warranted for every client. The extent of spiritual inquiry will depend on the specific type of presenting issue, and whether the client presents with an overtly spiritual world view or a spiritual issue as the primary or secondary focus of treatment. Progressive review of spiritual information is warranted, especially when the primary presenting issue is psycho-spiritual in nature. A range of assessment tools, both self-report measures and interview protocols as well as undertaking a general spiritual history can be used to help the assessment process (see boxed information). In addition, Hill and Hood (1999) provide a comprehensive list of measures of religiosity, including their psychometric properties.

The inclusion of papers related to spirituality at the 2008 APS conference was a positive sign that the spiritual domain is being recognised as relevant to psychological practice and client care. It suggests that as a profession we are slowly moving towards a more integrated and holistic understanding of health care, one that is inclusive of the spiritual domain. The rise of APS Interest Groups in the areas of Christianity, Islam and Buddhism further attests to this inclusion of spirituality. As psychologists we need to examine any perceptions that may prevent our considering the spiritual domain of human experience when formulating and delivering psychological care. This is especially the case when our clients need and want their spiritual needs and experiences taken into account in relation to their psychological and physical health care.

The author can be contacted at mtproctor@optusnet.com.au or mtproctor@spirituality-australia.com.  

References

Anderson, M.J., Marwit, S.J., Vandenberg, B., & Chibnall, J.T. (2005). Psychological and religious coping strategies of mothers bereaved by the sudden death of a child. Death Studies, 29, 811-826.

Hill, P.C., & Hood, R.W. Jr. (Eds) (1999). Measures of religiosity. Alabama: Religious Education Press.

McMinn, M.R., & Hall, T.W. (2000). Christian spirituality in a postmodern era. Journal of Psychology and Theology, 28(4), 251-253.

Paluoutzian, R.P., & Park, C.L. (Eds) (2005). Handbook of the psychology of religion and spirituality. New York: The Guildford Press.

Plante, T.G., & Sherman, A.C. (2001). Faith and Health: Psychological Perspectives. Guildford: New York.

Proctor, M-T., & McLean, L. (in press). Reviewing the place of the spiritual domain in the clinical and psychotherapeutic setting: Framing and assessing issues within an attachment perspective. Psychology and Spirituality Society (PASS) 2008 Monograph.

Proctor, M-T., Miner, M., & Dowson, M. (in review a). The relationship between attachment to God, psychological health and spiritual maturity: Submitted to Review of Religious Research, January, 2008, resubmitted July, 2009.

Proctor, M-T, Miner, M., McLean, L., Devenish, S., & Ghobary Bonab, B. (in review b). Exploring Christians' explicit attachment to God representations: The development of a template for assessing attachment to God experiences. Journal of Psychology and Theology, submitted January, 2009.

Sperry, L. (2003). Integrating spiritual direction functions in the practice of psychotherapy. Journal of Psychology and Theology, 31, 3-13.

Slater, W., Hall, T.W., & Edwards, K.J. (2001). Measuring religion and spirituality: Where are we and where do we go? Journal of Psychology and Theology, 29(1), 4-21.