Implicit Spiritual Assessment: An AlternativeApproach for Assessing Client Spirituality

David R. Hodge

To provide optimal services, a spiritual assessment is often administered to understand theintersection between clients' spirituality and service provision. Traditional assessmentapproaches, however, may be ineffective with clients who are uncomfortable with spirituallanguage or who are otherwise hesitant to discuss spirituality overtly. This article orientsreaders to an implicit spiritual assessment, an alternative approach that may be more validwith such clients. The process of administering an implicit assessment is discussed, samplequestions are provided to help operationalize this approach, and suggestions are offered tointegrate an implicit assessment with more traditional assessment approaches. By using ter-minology that is implicitly spiritual in nature, an implicit assessment enables practitioners toidentify and operationalize dimensions of clients' experience that may be critical to effectiveservice provision but would otherwise be overlooked.

KEY WORDS; assessment; cultural competency; religion; spirituality; therapy

I t is increasingly realized that spirituality playsan important role in fostering health and well-ness (Koenig, King, & Carson, 2012). To help

social work practitioners understand this relationshipin cHents' lives, a spiritual assessment is commonlyrecommended as a routine component of practice(Canda & Furman, 2010; Fumess & Gilligan, 2010).Administering a spiritual assessment—as part ofa larger bio-psycho-social-spiritual assessment—provides a more holistic understanding of clients'realities, which in turn provides the basis for subse-quent practice decisions.

As a result of the time constraints that exist in ther-apeutic settings, spiritual assessment is widely con-ceptualized as a two-stage process: a brief preliminaryassessment followed—if clinically warranted—byan extensive comprehensive assessment (Canda &Furman, 2010; Pargament, 2007; Shafranske, 2005).The brief assessment consists of a few questions thatare typically administered to all clients (for example,"I was wondering if you are interested in spiritualityor religion?"). The purpose of the preliminary assess-ment is to determine the clinical relevance of spiritu-ality and to ascertain whether a comprehensiveassessment is needed. In situations where cHents' spir-itual beKefs and practices intei-sect service provision,practitioners can select from an array of comprehen-sive assessment tools to explore this intersection(Hodge & Limb, 2010).

Although this explicit approach to spiritual assess-ment represents an important contribution to theliterature, it may not be effective with all clients(Nelson-Becker, 2005). Some clients may benefitfrom what might be called an implicit spiritualassessment. In this approach, the use of traditionalspiritual or religious language is avoided. Instead,practirioners use terminology that is impHcidy spiri-tual in nature to explore potentially relevant con-tent. As such, an implicit assessment provides amethod to identify and operationalize dimensions ofclients' experience that may be critical to effectiveservice provision but would otherwise be over-looked in an explicit spiritual assessment.

Approximately two-thirds of direct practitionersaffiliated with NASW believe social workers needto become more knowledgeable about spirituality(Canda & Furman, 2010). Indeed, studies haverepeatedly found that most direct practitionersreport receiving minimal training in spiritualityduring their graduate educations (Canda & Fur-man, 2010; Sheridan, 2009). This article addressesthis knowledge gap by orienting readers to the pro-cess of conducting an implicit spiritual assessment asa supplement to existing assessment approaches.

The article begins by defining spirituality andreligion and noting contexts in which an implicitspiritual assessment may be particularly gemiane.The process of administering a spiritual assessment

doi: 10.1093/sw/swt019 ©2013 National Association of Social Workers 223

is discussed, and sample questions are provided tohelp practitioners implement this approach in prac-tice settings. The article concludes by offeringsome suggestions for integrating an implicit assess-ment with more traditional explicit approaches toassessment.



Spirituality is understood and expressed diverselyamong social workers (Hodge & McGrew, 2006)and the general public (Gallup & Jones, 2000).One way to conceptualize spirituality is in terms ofconnectedness with what is perceived to be sacredor transcendent (Hodge, 2001; Koenig et al.,2012; Pargament, 2007). As such, spirituality canbe seen as a fundamental human drive for transcen-dent meaning and purpose that involves connect-edness -with oneself, others, and ultimate reality(Canda & Furman, 2010; Cnsp, 2010).

Religion can be conceptualized as a shared set ofbeliefs and practices that have been developed overtime with people who have similar understandingsof the sacred or transcendent (Geppert, Bogen-schutz, & Miller, 2007; Koenig et al, 2012). Thesebeliefs and practices, which are designed to medi-ate an individual's relationship with the sacred, aretransmitted through community-based structuresor organizations (Canda & Furman, 2010). Theseorganizations can be traditional, such as the Catho-lic Church, or of more recent origin, such as theNew Age or Syncretistic movement. As such, reli-gion is relatively objective, concrete, and commu-nally oriented, whereas spirituality tends to bemore subjective, private, and personal.

Understood in this sense, spirituality and reli-gion are overlapping but distinct constructs.

Spirituality is posited to be a universal humanimpulse that may or may not be expressed in reli-gious forums (Derezotes, 2006). Thus, whereas spi-rituality is commonly manifested in an individual'srelationship with God (Wuthnow, 2007), a per-son's connection with the transcendent may bedisplayed in many forms, including those thatmight be considered secular in nature (Crisp,2010). In other words, the drive to construct asacred reality is expressed in a variety of relationallyoriented settings. This understanding of spiritualitysuggests two contexts in which an implicit spiritualassessment may be particularly germane.



Research with various samples suggests most clientswant to have their spiritual and religious beliefsintegrated into the therapeutic conversation(Arnold, Avants, Margolin, & Marcotte, 2002;Dermatis, Guschwan, Galanter, & Bunt, 2004;Mathai & North, 2003; Rose, Westefeld, & Ans-ley, 2001, 2008; Solhkhah, Galanter, Dermatis,Daly, & Bunt, 2009). A brief preliminary assess-ment helps to legitimize the topic and provides aforum for clients to explore issues that might other-wise have remained undiscussed (Nelson-Becker,Nakashima, & Canda, 2007; Richards & Bergin,2005). There are, however, at least two contexts inwhich an implicit spiritual assessment is particularlyuseful; (1) when spiritual language is perceived tobe irrelevant, and (2) when practitioners' level ofspiritual competence is questioned.

Spiritual Language Is IrrelevantFor some clients, the spiritual or religious languageused in an explicit preliminary assessment does notresonate with their personal worldviews. Asimplied by the above conceptualization of spiritu-ality, essentially anything can be imbued with tran-scendent significance (Crisp, 2010). In many cases,people construct a sense of meaning, purpose, andidentity outside the confines of traditional spiritualand religious settings.

For example, the sacred can include art, collect-ing, gardening, sports, nature, and a myriad ofother activities and entities (Griffith Sc Griffith,2002; Pargament, 2007). These endeavors can pro-vide a transcendent sense of meaning, purpose, andconnectivity for some individuals. Although thebeliefs and practices might be considered sectilar,they are effectively accorded a sacred role in clients'lives. In other words, the fundamental humandrive to construct a sacred reality is manifested insecular activities that provide people with a tran-scendent sense of meaning and purpose in theirlives (Crisp, 2010; Pargament, 2007).

For such individuals, typical spiritual terminol-ogy can seem like a culturally foreign languagethat is irrelevant to their lived experience. Indeed,some secular individuals consider the use of spiri-tual terminology to be offensive (Paley, 2008,2010). Even though secular activities may servewhat is essentially a spiritual function, these clients

224 Social Work VOLUME 58, NUMBER 3 JULY 2013

may be uncomfortable or even unwuling to discussthese functions in the context of an explicit spiri-tual assessment. In such cases, an implicit spiritualassessment provides a vehicle to identify the role ofthe sacred in clients' lives. Indeed, for such clients,an imphcit assessment may be the only way theirunderstanding of the sacred can be explored.

Clients' Perceptions of Practitioners' Levelof Spiritual CompetenceAlternatively, some clients may question practi-tioners' level of spiritual competence. Chents inthis category are comfortable with spiritual lan-guage but are unsure about the degree to whichthey can trust practitioners with a topic that is oftenintensely personal and private (Lewis, 2001). Inshort, they are hesitant to trust practitioners withsuch a private dimension of their being untü practi-tioners have demonstrated themselves to be com-petent and trustworthy handling spiritual issues(Richards & Bergin, 2005).

The helping professions have long struggledwith the issue of spiritual diversity. Committedatheists from Freud (1927/1964) to Ellis (1980)have attempted to pathologize devout spiritualbelief. Clients are often extremely sensitive to thesebiases and may assume practitioners hold similarviews (Richards & Bergin, 2005). Indeed, concernsabout practitioners' level of spiritual competenceare underscored by the fact that most social work-ers report receiving Uttle, if any, training on spiritu-ahty during their graduate educations (Sheridan,2009). Practitioners may inadvertently communi-cate disrespect for chents' spiritual beliefs and prac-tices because of a lack of training and awarenessregarding potentially sensitive issues.

Consequently, some chents may indicate thatthey are uninterested in discussing spirituaHty dur-ing the initial preliminary assessment (Richards &Bergin, 2005). Trust may be developed over time,however, as clients interact with practitioners. Animplicit assessment provides a way to gently easeinto the topic at a later point in therapy. Animplicit approach provides a forum in which prac-titioners can communicate interest, openness,receptivity, and respect for clients' beliefs andvalues (Canda & Furman, 2010). In other words,when clients question practitioners' level of spiri-tual competence, an implicit assessment may offera way to buüd mutual trust and respect. The

process of operationalizing such an assessment isdiscussed in the next section.

MOVING TOWARD AN IMPLICIT SPIRITUALASSESSMENTIt is important to note that assessment is, in a cer-tain sense, an ongoing process (Canda & Furman,2010). Although a biopsychosocial assessment istypically conducted at the beginning of therapy,practitioners must remain open to revising theirinitial suppositions as additional information isobtained during subsequent sessions. Simüarly, oneshould remain open to the possibüity that spiritual-ity plays an important role in chents' lives, eventhough the initial preliminary assessment indicatesthat spirituality is not a sahent ufe dimension.

Toward this end, practitioners' "spiritual radar"should be turned on throughout the counselingprocess. The aim is to develop sensitivity to inter-actions that suggest the possibüity that spirituality isa relevant dimension in clients' lives (Griffith 6fGriffith, 2002). Particularly helpful in this regard islistening for implied spiritual content in clients'narratives and attending to emotional shifts in cli-ents' affect as they relate their stories.

Listening for Language that Connotesthe SpiritualA key component in operationalizing an implicitspiritual assessment is listening for language thathints at the presence of the spiritual. As notedabove, explicit spiritual language may not resonatewith some clients. In the same way, practitionersmay not pick up on implicitly spiritual language(Pargament & Krumrei, 2009). Accordingly, it isimportant to listen for phrasing that suggests theexistence of spiritually relevant topics in the courseof the clinical dialogue (Griffith & Griffith, 2002).

For example, speaking in extremes or usingmajor polarities may offer insight into clients' spiri-tuality (Pargament, 2007). When clients refer tosomething as faultless, perfect, or flawless, theymay be attributing aspects of divinity to the entity.Alternatively, clients may fixate on the negative.For example, when clients demonize someone, itmay be a sign that the individual has violated whatis perceived to be sacred.

Language that parallels spiritual thoughts andbehaviors can indicate the existence of spirituallysignificant content. Clients may describe beliefs.

HODGE / Implicit Spiritual Assessment: An Alternative Approach for Assessing Client Spirituality 225

practices, and experiences that do not seem explic-itly spiritual but reflect an underlying spiritualdimension. For example, cHents may participate incertain activities on a regular basis that are per-ceived to be highly meaningful. Such activitiesmay represent rituals or ceremonies and may servea transcendent purpose in clients' lives, engender-ing a sense of profound meaning and purpose(Crisp, 2010).

In short, practitioners should Hsten carefully forterms and phrases that signal the presence of spiri-tual issues below the surface. Clients often describethoughts, experiences, and feehngs that parallel thespiritual. These descriptions can signify the exis-tence of clinically relevant topics that require fur-ther exploration.

Attending to Emotional ShiftsIn addition to listening to clients' language, practi-tioners should also attend to clients' emotions.Many people experience spirituality primarilythrough their feelings (Pargament & Krumrei,2009). Indeed, spiritual experiences can produceespecially strong emotions.

Encounters wth the transcendent often engen-der positive feelings (Exline, Park, Smyth, &Carey, 2011). Interactions with the sacred fre-quently result in feelings of awe, reverence, andsolemnity; pleasure, joy, and excitement; andmeaning, hope, and purpose. Although positiveemotions are perhaps more commonplace, interac-tions with the sacred can also produce negativeemotions, such as anger, discouragement, andregret. For example, upon moving to a new geo-graphic location, a client might express deep regretover having to give up a sacred activity that nour-ished her soul.

Practitioners should be alert for changes in clientaffect during the flow of conversation (Griffith &Griffith, 2002). The presence of an emotion mayindicate that a spiritually relevant topic has beentouched on. For example, a hint of emotion in aclient who is otherwise depressed—such as a spar-kle in the eye or a smile—may indicate that thepractitioner has broached a spiritually relevanttopic.

Understanding what elicits powerful emotionscan provide important insights into clients' rela-tionship with the transcendent. In addition towatching for these types of emotional displays,practitioners can also facilitate this process through

active exploration (Crisp, 2010). The next sectiondiscusses how practitioners can facilitate such anassessment.



When clients' language or affect raises the possibil-ity that spirituality may be related to service provi-sion, it is usually appropriate to explore thispossibility in more depth. In such circumstances, itis critical that client autonomy be respected(Nelson-Becker, 2005). Effective therapy is predi-cated upon the creation and maintenance of a non-coercive atmosphere in which self-determination isrespected (Richards & Bergin, 2005). Practitionersmust carefully monitor clients' reactions to ensurethey remain supportive of the process throughoutthe exploration.

With this caveat in mind, the possible presenceof spirituality can be explored through the use ofvarious questions that imphcitly tap spirituality.Sometimes called psychospiritual (Pargament,2007) or existential (Griffith & Griffith, 2002) ques-tions, these items are designed to elicit contentabout clients' relationship to the sacred or transcen-dent dimensions in a context in which a moredirect exploration of spirituality is contraindicated.Some sample questions for conducting an implicitassessment are provided in Table 1. Adapted from avariety of sources, these questions can be used toindirectly explore the role of spirituality (Canda &Furman, 2010; Griffith & Griffith, 2002; Hodge,2001; Pargament, 2007; Pargament & Krumrei,2009).

Toward this end, various questions from thistable can be integrated into the flow of conversa-tion as needed. In a traditional comprehensiveassessment, it is common practice to flesh out cli-ents' spiritual stories across their life spans, typicallymoving from childhood through to the present,and even on into the future (Canda & Fumian,2010; Hodge, 2001; Pargament & Krumrei, 2009).Although the questions are presented in keepingwith this convention, it should be stressed that thisframework may not be applicable when conduct-ing an implicit assessment. Practitioners should bealert to the possibility that spirituality may be clini-cally relevant at any time and ask questions thatinvite a deeper exploration of spirituality when cli-ents' words or emotions allude to the presence ofthe sacred.

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Table 1: Implicit Spiritual Assessment QuestionsPast spirituality

What sort of experiences stood out for you when you were growing up?

When you think back, what gave you a sense of meaning (or purpose, or hope for the Eiture)?

When were you happiest (or most joyful)?

As you consider your life, what accomplishments are you particularly proud of?

How did you cope with chailenging situations in the past?

Present spirituality

Understanding how the transcendent or sacred is manifisted

When do you feel most fully alive?

Who/what gives you a sense of purpose and meaning in life?

What causes you the greatest despair/suffering?

Can you describe recent experiences (for example, "aha moments") that sparked new insights?

What things are you most passionate about in life?

If you had a magic wand, what would you change to make your life more meaningful?

What helps you feel most aware (or centered) ?

Who/what do you rely on most in life?

Who/what do you put your hope in?

For what are you most deeply grateftd?

To whom/what are you most devoted?

To whom/what do you most freely express love?

What pulls you down and discourages you?

When in your life have you experienced forgiveness?

What are your deepest regrets?

Who best understands your situation?

Understanding how spirituality facilitates healthy Wellness, and coping

What rituals/practices are especially important (or significant) to you?

What kinds of experiences provide you with the deepest sense of meaning in life?

How do you commemorate special occasions/accomplishments?

At the deepest levels of your being, what strengthens (or nurtures) you?

Wliat sustains you through difficulties?

What sources of strength do you draw on to keep pressing forward?

What nourishes your soul?

Where do you find a sense of peace (or inspiration)?

When you are in pain (or afraid), where do you turn for comfort?

How have difFicult situations changed your life for the better?

What gives you the strength to carry on day after day?

What helps you get through times of difficulty (or crisis)?

Who supports you in hard times? How so?

Future spirituality

What are you striving for in life?

What are your goals for the future?

If you had just a year to live, what are the most important things you would like to accomplish?

Why is it important that you are here in this world?

After you are gone, what legacy would you like to leave behind?

How would you like people to remember you after you are gone?

The first set of questions—past spirituality—isdesigned to explore the intersection between spi-rituality and clients' past, and perhaps particu-larly, their family of origin. Understanding howtranscendent dimensions of existence functionedin the past provides the context for under-standing how these dimensions function in the

present (Hodge, 2001). Similarly, understandinghow clients coped with previous challengessuggests possible coping strategies that iTiight beleveraged to ameliorate current problems (Canda& Furman, 2010).

The second set of questions—present spirituality—addresses client's contemporary experience of the

HODGE / Implicit Spirittial Assessment: An Alternative Approach fir Assessing Client Spirituality 227

transcendent. This set is broken into two relatedgroups. As implied by the heading, the first groupexamines how perceptions of the transcendent aremanifested. These questions may be parricularlyhelpful in fleshing out clients' understanding of thesacred. The second group examines how spiritualitymay facilitate health, Wellness, and coping. Ques-tions from this group can be used to explore strate-gies that might be used to address problems. Forexample, in the face of present difficulties, rituals orpractices that foster Wellness may have been ignored.Identifying and reinsdtuting such salutary pracricesmay assist cHents on their joumey toward Wellness(Saleebey, 2009).

The final question set—future spirituality—explores the role of the transcendent in futureplans. Future aspirations are also a part of clients'sacred narratives. In the same way that past and pre-sent beliefs can shape current beliefs and practices,clients' views regarding their future can also shapepresent functioning. Accordingly, the explorationof future plans, goals, dreams, and expectations canprovide important therapeutic insights (Hodge,2005).

It is important to note that there is no singlemethod for asking these questions in therapeuticsettings. Assessment is a complex, mulrilevel pro-cess in which every client affirms a unique under-standing of reahty (Fumess & Gilligan, 2010).Accordingly, the questions should be adapted andintegrated into the therapeutic conversation in a•way that makes sense in the context of clients' indi-vidual value systems (Hodge, 2001). Askingimplicit spiritual questions, listening for languagethat connotes the sacred, and attending to emo-tional shifts is a complex process that varies fromsetdng to setting. Yet, as the following exampleillustrates, this process can lead to significant thera-peutic breakthroughs.

Ken, a 50-year-old Latino male, sought therapyfor persistent feeHngs of fatigue and depression. Apreliminary assessment revealed no religious affilia-tion or interest in spirituality. Counseling pro-duced little improvement. That changed,however, when the practitioner asked about prac-tices that had formerly nourished his soul. A sparkappeared in Ken's eyes, and the tone of his voicebecame slightly more animated as he spoke aboutthe place that music once occupied in his life. Incollege. Ken had an extensive album collection,played in a band, and was iiTmiersed in the local

music scene. As the demands of his accountingcareer steadily increased over the years, his passionfor music was slowly pushed to the margins of hisHfe. Sensitivity to the spiritual dimension aHowedthe practitioner to engage Ken in a discussionabout how his drive for professional success hadresulted in Ken's neglect of a sacred activity thathelped animate his life. Facilitating Ken's transitiontoward a more personally authentic path that nur-tured his soul became a central focus of subsequentsessions.

Assessment focuses on understanding the inter-section between the sacred and Wellness. The goalis to understand the relationship between clients'understanding of the transcendent and service pro-vision. In some cases, this may entail moving froman implicit assessment to a comprehensive assess-ment, a topic discussed in the following section.

MOVING FROM AN IMPLICIT ASSESSMENT TOA COMPREHENSIVE ASSESSMENTThe administration of an implicit assessment mayreveal the presence of spirituality as a clinically rele-vant factor. As the above example illustrates, someclients report secular activities that funcrion assources of spiritual meaning in their lives (Crisp,2010). Alternatively, in situations where clients areinitially hesitant to trust practitioners, an implicitassessment may reveal more traditional understand-ings of spirituality. In either case, it may be helpfulto use a comprehensive assessment to provide bet-ter understanding of the role of spirituality in cli-ents' lived experience.

A conceptual model for integraring an impHcitassessment with an explicit spiritual assessment isdepicted in Figure 1. As can be seen, the processbegins with a brief preliminary assessment. If thebrief assessment reveals that spirituaHty is potentiaHyrelated to service provision, then the practitionergenerally moves directly to a comprehensive assess-ment. If the brief assessment indicates spirituaHtyis unrelated to service provision, the practitioneradopts an impHcit approach exploring potentialexpressions of spirituaHty if cHents' language or affectsuggest such an exploration is warranted.

If an implicit assessment indicates that the tran-scendent plays a salient role in clients' lives, thenone of the many comprehensive tools that havebeen developed can be used to flesh out clients'spiritual reality. A comprehensive tool can often beused regardless of whether or not cHents view

228 Social Work VOLUME S8. NUMBER 3 JULY 2013

Figure 1 : Conceptual Model for Integratingan Implicit Assessment with an Explicit

Spiritual Assessment

Caring, respeclfiil, spiritually empathetic environment

themselves as spiritual or secular. For example, inthe latter case, a spiritual life map might be used todiagram clients' primary sources of meaning andhope over the course of their lives (Hodge, 2005).The life map can be assigned as homework, savingvaluable therapeutic time, and discussed in thenext session. The physical depiction of clients'sources of strength can elicit fresh therapeuticinsights, uncover unoperadonalized assets, and sug-gest new strategies to ameliorate problems.

Central to the assessment process, however, is thecreation of a caring, respectful, spiritually empatheticenvironment (see Figure 1). Indeed, the success ofthe therapeutic enterprise itself rests upon the crea-tion of such an atmosphere. Toward this end, it iscritical to obtain clients' consent before moving to acomprehensive assessment. Because of the pro-foundly personal nature of spirituality, practitionersshould carefully monitor clients' verbal and non-verbal responses to ensure they consent to the assess-ment process from start to finish.

In light of the sensitive nature of spirituality andthe attendant potential for hann, the choice toaddress spirituality in a more in-depth manner callsfor careful consideration. For example, practition-ers might assess their level of competence regardingclients' spiritual beliefs and values (NASW, 2001).Similarly, practitioners should possess sufficienttraining to ensure any spiritual strategies used intherapeutic settings can be implemented in a pro-fessional manner (Hodge, 2011). In certain situa-tions, the results of the initial assessment maysuggest that referral to other practitioners withmore expertise with a given population (or inter-vention) is in clients' best interests.

The discussion of cultural competency high-lights the issue of practitioners' level of personal

comfort with spirituality. For a variety of reasons,some social workers believe that spirituality shouldnot be addressed in clinical settings (Canda &Furman, 2010). An implicit assessment offerssuch individuals a vehicle for discussing spirituahtyin a more oblique manner. While practitionersmust ensure they possess sufficient levels ofcultural competency to provide effective services,an implicit assessment provides therapists who areuncomfortable with traditional spiritual language away to discuss clinically salient transcendentdimensions.

Another option that covers terrain similar to thatof an implicit spiritual assessment is an explicit exis-tential assessment. Readers interested in thisapproach might consult the work of Yalom (1980).Although all therapists can likely benefit fromYalom's work, practitioners who are uncomfort-able with traditional spiritual language might findit especially helpful.


Traditional spiritual assessment approaches repre-sent a good fit for many clients (Canda & Furman,2010; Hodge & Limb, 2010). For some, however,these methods may not represent valid approaches.Such clients may be better served by an implicitspiritual assessment.

For example, when working w t h clients whobelieve spiritual language is irrelevant to their livedexperience, an implicit spiritual assessment pro-vides a means to explore the transcendent dimen-sion. Similarly, an implicit assessment offerspractitioners a way to build trust and rapport whenclients are hesitant to trust practitioners with ahighly sensitive subject. In short, an implicit assess-ment helps practitioners identify and operationalizedimensions of clients' experience that might other-wise be overlooked in a traditional assessment.Consequently, it is an approach that essentially allpractitioners can benefit fiom incorporating intotheir "assessment toolbox."

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David R. Hodge, PhD, is associate professor of social work,

Arizona State University, and senior nonresident fellow. Program

for Research on Religion and Urhan Civil Society, University of

Pennsylvania. Address correspondence to the author at Mail Code

3920, 411 N. Central Avenue, Phoenix, AZ 85004-0689.

Original manuscript received February 4, 2012Final revision received luly 14, 2012Accepted July 31, 2012Advance Access Publication June 13, 2013

230 Social Work VOLUME 58, NUMBER 3 JULY 2013

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