Elder Care Interprofessional Provider Sheets

Spirituality: Conducting Spiritual Assessments with Older Adults

David R. Hodge, PhD, School of Social Work at Arizona State University and
Center for Spirituality, Theology, and Health, Center for Aging and Human Development at Duke University Medical Center  

February 2017

TIPS FOR CONDUCTING SPIRITUAL ASSESSMENTS WITH OLDER ADULTS
  • Work within the spiritual and religious parameters of patients.
  • Develop familiarity with different approaches to spiritual assessment and their associated strengths.
  • Select an assessment approach that fits the unique needs, interests and values of individual patients.

Spirituality is central to the self-identity of many older adults. It informs beliefs and practices in an array of areas that can help clinicians understand a patient's family and marital relations, diet, communication and caregiving styles, finances, gender interactions, grieving, and medical care. As just one example, Muslims or Orthodox Jews may not want to take medications derived from pork.

Spirituality is also an important source of inner strength. When appropriate, encouraging patients to engage in spiritual practices such as prayer, scripture reading, meditation, and worship music can enhance wellness, coping, and recovery.

Clinicians should take spirituality into account so that barriers that might inhibit effective clinical care can be removed, and strengths that facilitate salutary outcomes can be operationalized.

Understanding Spirituality and Religion

Spirituality and religion are overlapping but distinct constructs. Spirituality is commonly understood to refer to an individual's subjective relationship or connection with God, or more broadly the sacred or transcendent. Religion, on the other hand, is viewed as a set of beliefs and practices that have developed over time by individuals who share similar understandings of the sacred.

Some older adults, however, may view spirituality and religion as essentially interchangeable concepts. The figure depicts the ways in which individuals may self-identify.

It is important to understand patients' definitions and work within the parameters of their worldview when addressing spirituality. To that end, clinicians can perform a brief assessment to help them understand a patient's spirituality.

Brief Assessment

Spiritual assessment is typically conceptualized as a two-step process to conserve clinicians' and patients' time. The first step is a brief preliminary assessment to ascertain if a patient's spirituality potentially intersects with their care. If the brief assessment reveals spirituality is likely unrelated to care, then the formal assessment process ends.

 

 

Examples of questions recommended for use in a brief assessment include: 

  1. I was wondering how important spirituality or religion is to you? 
  2. Do you attend a Faith community or belong to some other type of religious or spiritual group? 
  3. Are there particular spiritual beliefs or practices you find especially helpful in dealing with challenges? 
  4. How has your spirituality shaped your understanding and response to your current situation?

If the brief assessment suggests that spirituality may be related to providing services to the patient, then a social worker or chaplain referral for a more comprehensive assessment can provide the necessary information so that services can be adapted to take into account a patient's spiritual beliefs and practices.

Comprehensive Assessment

Older adults' communication styles, personality traits, and cultural backgrounds vary from person to person, along with the nature of the services provided and the amount of time available to conduct an assessment. Consequently, no one single assessment approach will fit every clinical setting. Different clinician-client dyads call for different assessment approaches.

The following table lists a number of approaches for conducting spiritual assessments. Each is described here and more detail can be found in the Hodge reference on the resource list.

Spiritual Assessment Approaches
Spiritual Histories
  • Appeal to highly verbal older adults
  • Good fit with clients from cultures that value story-telling
  • Conducive to building a therapeutic alliance
  • Relatively easy to administer
  • Approach is readily understood by clients
Spiritual Lifemaps
  • Appeal to older adults who value creativity and art
  • Honors cultures that value symbols to convey information
  • Good fit with less verbal older adults
  • Approach readily understood by clients
  • Possible to assign as therapeutic homework
Spiritual Genograms
  • Explores family of origin issues related to spirituality
  • Implicitly communicates respect for extended family
  • Can identify previously unrecognized family strengths
  • Depicts problems in family systems (interfaith couples)
  • Identify areas of commonality (same-faith couples)
Spiritual Eco-maps
  • Highlights resources in older adults' environments
  • Can mitigate concerns about discussing sensitive topics
  • Quick and relatively easy to construct
  • Visual presentation can foster self-understanding
  • Can integrate into a broader psychosocial assessment

Verbal Spiritual Histories

With this approach, a series of questions are used to assist older adults in telling their spiritual stories. As they relate their personal spiritual narratives, clinicians incorporate clinically relevant questions into the conversation. The process is comparable to conducting a family history.

Spiritual Lifemaps

Spiritual lifemaps are an illustrated account of an individual's relationship with God or the sacred over time. As such, lifemaps represent a pen-and-paper alternative to spiritual histories. Drawing pencils and other media are used to portray spiritually significant life events on a large sheet of paper. In a manner analogous to road maps, lifemaps tell us where we have come from, where we are now, and where we are going.

Spiritual Genograms

While spiritual histories and lifemaps focus on a single lifespan, spiritual genograms depict spiritual dynamics across at least three generations. Colors are used to represent religious affiliations across the family system, and various symbols are used to indicate spiritually significant events (e.g., baptisms, visions, etc.). The resulting genogram provides a snapshot of the overall spiritual composition of the family system that helps both older adults and clinicians understand the flow of spirituality through time.

Spiritual Eco-Maps

The aforementioned approaches focus on a portion of older adults' spiritual stories across time, typically across one to three generations. In contrast, eco-maps highlight spiritual systems in an individual's current environment. A circle representing the patient is placed in the center of a paper and significant spiritual systems are depicted as circles around the client (e.g., God, rituals, etc.). Various lines connect the patient with the spiritual systems, and relate information about the character of their relationships with those systems. The end result is a depiction of a patient's relationships to key spiritual systems in their environments.

Who Does the Comprehensive Assessment?

Comprehensive assessments can be performed by chaplains, social workers, physicians or nurses. In busy practices without a multiprofessional team, primary care clinicians can have patients complete an assessment (e.g., a lifemap) on their own for later review by the clinician.

How to Use the Assessment Results

The information obtained from the assessment is used to tailor service provision. The exact nature of the tailoring is dependent upon a variety of factors including the nature of the services provided. For example, a therapist might incorporate a patient's spiritual beliefs into cognitive-behavioral therapy self-statements. Or, in a hospital setting, a nurse might assure that a patient has access to spiritual resources that facilitate coping, like meeting with clergy, availability of scriptures, attending services, etc.).

In the end, the goal is to eliminate spiritually-based impediments to quality care and leverage a patient's spiritual strengths to foster wellness and self care.

References and Resources

Hodge DR. Spiritual assessment in social work and mental health practice. New York, NY: Columbia University Press. 2015. 
Koenig HG, King D, Carson, VB. Handbook of religion and health (2nd ed.). New York: Oxford University Press. 2012.
Richards PS, Bergin AE. Handbook of psychotherapy and religious diversity (2nd ed.). Washington, DC: American Psychological Association. 2014.