Native Americans and Brief Spiritual Assessment: Examining and Operationalizing the Joint Commission's Assessment Framework

The largest and most prominent health care accrediting organization in the United States is the Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations or, more commonly, as JCAHO (2009). The interrelationship between the Joint Commission and the field of social work is evidenced by the fact that NASW (2004) maintains a partnership with the Joint Commission. In addition to accrediting most of the nation's hospitals, the Joint Commission also accredits thousands of other organizations providing health and mental health services. At the turn of the century, the Joint Commission revised its accreditation standards to require the administration of a spiritual assessment (Hodge, 2006b). Spiritual assessments are now mandated in numerous settings, including hospitals, home care organizations, long-term care facilities, and behavioral health care organizations providing addiction services. This requirement is consistent with the views of most social work practitioners. Research has repeatedly found that the majority of practitioners affirm the importance of conducting a spiritual assessment in practice settings (Canda & Furman, 1999; Carlson, Kirkpatrick, Hecker, & Killmer, 2002; Heyman, Buchanan, Musgrave, & Menz, 2006; Murdock, 2005; Sheridan, 2004; Sheridan & Amato-von Hemert, 1999; Stewart, Koeske, & Koeske, 2006). As Weaver (2004) observed, helping professionals are disproportionately likely to encounter Native American clients in mental health settings. Due to a number of factors, including a history of oppression (Weaver & Brave Hart, 1999), Native Americans are disproportionately likely to wrestle with mental health challenges (Beals et al., 2005; Harris, Edlund, & Larson, 2005; Stiffman et al., 2006). Higher rates of challenges result in higher levels of service use. Harris et al. (2005) found that among those with one or more mental health symptom (N = 406), 42.32 percent of Native Americans had used mental health services, a percentage significantly higher than those for African Americans, Asians, and Latinos. Indeed, in absolute terms, Native Americans recorded the highest percentage of mental health service use across all groups surveyed (Harris et al., 2005). In theory, the Joint Commission's spiritual assessment requirements represent a positive development for Native American users of health care services. Although no single Native culture exists (Fuller-Thomson & Minkler, 2005), a number of values are shared among many tribes. Among these commonalities is a shared emphasis on spirituality (Cross, 2001). Indeed, spirituality is widely cited as a particularly important component of many Native cultures (Frame, 2003; Gesino, 2001 ; Graham, 2002). Furthermore, spirituality is commonly viewed as essential to the promotion of health and wellness (Gilgun, 2002; Lowery, 1999). In other words, spirituality is typically viewed as a critical strength that must be operationalized to address the challenges Native people face (Cross, 1997; Limb & Hodge, 2008; Stone, Whitbeck, Chen, & Johnson, 2005). Concurrently, it should be noted that common Native understandings of spirituality differ from those affirmed in the dominant secular culture (Cross, 2001). This raises the possibility that the spiritual assessment requirements developed by the Joint Commission may conflict with Native understandings of spirituality. All human constructions tend to reflect the values of their designers (Tjeltveit, 1999). Assessment frameworks developed by dominant groups often implicitly reflect value systems that conflict with the values of minority groups (Gilligan, 1993). Indeed, numerous authors have argued that Western therapeutic approaches conflict with many Native worldviews (Coates, Gray, & Hetherington, 2006; Yellow Bird, 2004). Consequently, services provided by social workers and other mental health professionals are often perceived to be, at best, ineffective (Walls, Johnson, Whitbeck, & Hoyt, 2006). …