Teaching christian faith integration in psychological assessment courses.

Adams, Wayne ; Mcminn, Mark R. ; Thurston, Nancy 等

Within the existing literature that emphasizes the integration of faith and psychology, topics related to psychological assessment are rare inclusions. Yet, it is commonly recognized that assessment measures provide useful clinical information. This article highlights the domain of psychological assessment as fertile ground for integrating psychology with spirituality. Three graduate-level faculty members who each teach psychological assessment courses in a clinical training program describe specific ways they integrate Christian faith and psychological assessment in the classroom. Foci for future efforts that would bring the areas of faith and psychological assessment together are described along with some of the benefits such efforts would yield, especially for clinical practice.

An adage offered freely in psychology training programs is that effective treatment requires effective assessment. Fortunately, psychological assessment is a credible endeavor that informs treatment for many practitioners. As part of the American Psychological Association's (APA) Professional Assessment Work Group (PAWG), Meyer et al. (2001) presented results obtained from 69 meta-analyses pertaining to psychological assessment and 57 meta-analyses of testing done in general medical settings. The PAWG presented compelling evidence for both the effectiveness of psychological assessment and its comparability with medical assessment (see also Clay, 2006). Moreover, it is clear that clinicians who base their treatments only on clinical interviews have an incomplete understanding of their patients and clients (Meyer et al., 2001).

Psychological Assessment is one of the foundational competencies identified by the American Psychological Association (Fouad, Grus, C.L., Hatcher, R. L, Kaslow, NJ., Hutchings, P. S., 2009). Table 1 denotes the recommended assessment knowledge, skills, and attitudes that should be demonstrable when a trainee enters practicum, internship, and independent practice. Treatment intervention is another foundational competency domain that occupies a similar amount of space in APA's competency guidelines. However, in faith integration journals and professional conferences sponsored by organizations such as Christian Association for Psychological Studies (CAPS), intervention dramatically overshadows assessment. A quick search of back issues of this journal from 2001 to 2013 revealed that just six published articles, of more than 100, featured psychological assessment content. Perusing conference programs of organizations focusing on the integration of faith and learning (e.g., CAPS) yielded relatively few inclusions of presentations or posters related to assessment. Why is there such an apparent void in the integration of psychology and Christianity and assessment?

TABLE 1

Suggested Assessment Competencies Domains to be Achieved by practicum,
Internsbip and Independet Practice, and "Bebavioral Anchors (1)"

Behavioral Anchors for Different Professi onal Levels

Domain Practicum Internship

Measurement and Basic Under supervision,
Psych [C]metrics knowledge selects
 of scientific assessment
 and measures
 theoretical appropriate
 aspects of to common referral
 test questions,
 construction and with attention
 and to issues of
 interviewing reliability and
 validity

Evaluation Basic knowledge Awareness of
Methods of strengths and
 administration Limitation of
 and administration.
 scoring of scoring and
 traditional interpretation of
 assessment traditional
 measures, assessment
 including MMSE including
 technological
 advances

Applications of Awareness of Under supervision,
Methods need to base selects
 diagnosis on appropriate
 multiple breadth of
 sources of assessment tools
 information. chat reflect
 and need to awareness of
 select patient
 measures population
 appropriate to served
 problem

Diagnosis Basic knowledge Uses test results
 of range and history,
 of normal and along with
 abnormal developmental/
 behavior and diversity
 how sensitivity and
 this relates to diagnostic acumen
 existing to formulate
 diagnostic differential
 systems diagnosis, with
 supervision;
 awareness of
 literature
 apparent; works
 not
 to foreclose
 prematurely on
 formulation
 prematurely

Conceptualization Preparation of Utilizes
and basic systematic
Recommendations reports reflect approaches in
 associated gathering data to
 theoretical inform clinical
 underpinnings decision-making,
 related to rest and reflected in
 results case reports;
 aware of
 potential
 harm of
 misinterpretation
 by
 others and works
 to minimize

Communication of Basic knowledge Under supervision,
Findings of writes a basic
 format for psychological
 formal reports report including
 and writes cognitive and
 sections personality
 reflecting an components, and
 appreciation demonstrates
 of precision an ability to give
 and verbal feedback
 conciseness to client
 effectively

Domain Independent
 Practice
Measurement and Independently
Psych [C]metrics selects and
 implements
 assessments that
 arc
 psychometrically
 sound, while
 sensitive to issues
 such as ethnic
 diversity and
 disability

Evaluation Independently
Methods understands
 strengths and
 limitations of
 diagnostic
 approaches and
 interpretation of
 results from
 multiple measures
 for diagnosis
 and treatment

Applications of Judiciously selects
Methods and administers
 a variety of
 assessment tools,
 integrating results
 in formulating
 opinion related to
 referral
 question(s)

Diagnosis Diagnostic
 formulation and
 Recommendations
 reflect
 comprehensive
 integration of
 test
 findings, history,
 observations, and
 related literature
 (when available).
 Seeks consultation
 with more
 complicated cases.

Conceptualization Independently and
and accurately
Recommendations conceptualizes the
 multiple
 dimension of case
 based on
 assessment findings
 and history;
 follows up with
 client to judge
 quality of
 recommendation(s);
 sensitive to
 harmful use of
 test
 results and works
 to minimize

Communication of Professional Iv
Findings communicates
 results of
 comprehensive
 assessment
 effectively in
 written
 and verbal forms,
 with sensitivity
 and respect;
 therapeutically
 promotes
 meaningful
 recommendations

There are likely numerous reasons for this paucity of interest. First, whereas psychological assessment is the primary domain of psychologists in the larger mental health industry, the faith integration movement has tended to reach beyond the boundaries of licensed psychologists to address other mental health professionals and educators. Integration issues specific to assessment might be perceived as exclusivist or less relevant to other mental health professionals. Second, it could be argued that historical pastoral care practices are more closely aligned to psychological interventions than to assessment practices, making psychotherapeutic integration a more natural conversation than assessment-related themes in integration. Third, assessment generally requires conformity to standardized procedures, which might be perceived as lending themselves to less innovation or creativity than intervention practices. That is, the "spiritual way" of administering and scoring an intelligence test would not differ from any other way of administering and scoring the test, whereas the same may not hold true for a particular psychological intervention. Nevertheless, assessment reports are value-laden, and therefore a report generated by, for example, an animist, Christian, or Muslim believer, may well differ in tone as well as in how test results are interpreted or applied within recommendations. Fourth, there is a belief among many clinicians that few third parry payers reimburse for psychological testing. While that may be true for some insurance carriers and in some geographic regions of the country, testing charges are generally approved if "necessity" is documented and testing is completed with objectives being clearly articulated. Most resistant insurers can be convinced when a parallel argument is made using a medical model: would a medical work-up be considered "standard of care" if lab or imaging tests were disallowed? With parity laws now in place, making this argument and getting approvals has become even easier. Nonetheless, the erroneous belief in non-reimbursement for any psychological testing remains common among practitioners. Whatever the explanation for the relative lack of integration emphasis on assessment, we are grateful for this opportunity to reflect on our own practices and experiences as educators of psychologists in an explicitly Christian doctoral training program that is accredited by the APA Commission on Accreditation. Each of us teaches one or more courses in assessment, attempting to help our students think and practice in integrative ways. In this paper we describe some of the methods we use to help students think integratively about assessment. What follows is a listing of several of our basic assessment courses each with narrative that describes what faith integrative concepts and activities we have found to be meaningful inclusions.

Psychometrics and Test Development

In our program, we opt to teach psychometrics in the First semester of the first year of training. This socializes students to understand the scientific moorings of the profession while also helping prepare them for the assessment courses and practicum placements that follow.

I (McMinn) find that teaching psychometrics does not lend itself as naturally to integration as teaching other courses such as Cognitive-Behavioral Psychotherapy or Religious and Spiritual Issues in Psychotherapy. There is no distinctively Christian way to compute a standard error of measurement, for example! Still, over seven years of teaching the Psychometrics and Test Development course I have become increasingly comfortable incorporating implicit and explicit integration strategies in the classroom. What follows is a brief description of several integration topics that we consider in the course.

The scientific method and humility. Humility is gaining momentum as an important topic of scientific study, including study by those involved in the contemporary faith integration movement (e.g., Davis et al., 2011; Exline & Hill, 2012; Worthington, 2007). One of the first integration discussions I bring up in the psychometrics course pertains to science as an activity rooted in humility, noting also that humility is a virtue evident in scripture (e.g., Philippians 2:1-11 and discussed by Christian philosophers and theologians throughout many centuries. Though most people know scientists who are not particularly humble human beings, the activity of science itself has an intrinsic dimension of humility. We don't simply assume something is true because we believe it to be so, but instead expose our ideas to empirical scrutiny and abandon the ones that are not supported.

To introduce humility, I begin by showing robust evidence from cognitive and social psychology that we humans tend to overestimate both our abilities and the correctness of our ideas. This also has a theological dimension insofar as it is related to the noetic effects of sin (Moroney, 2000). After providing compelling evidence that our own estimates of ourselves are not particularly accurate, we then consider how important it is to have a system that assures a measure of humility in how we assess one another and ourselves. In psychological assessment, this system takes the form of psychometrics. This provides a backdrop for the tools we explore in subsequent weeks of the course, including reliability and validity, item analysis, and test development. With regard to the functional competencies of training in psychology, this conversation about science and humility lends itself to the scientific, theoretical, and contextual bases of test construction.

Responsible use of power as Christian virtue. First year doctoral students do not typically enter training with a complete understanding of the power

assigned to psychologists involved in psychological assessment. Power is a primary theme throughout scripture, with God repeatedly denouncing injustice and the misuse of power--whether the imbalanced scales mentioned in Old Testament passages (e.g., Proverbs 20:23, NW) or Jesus explicitly teaching his disciples that greatness comes through serving others (e.g., Matthew 9:33-35).

Throughout the psychometrics course I bring in case material from my own assessment work, always de-identified to protect the confidentiality of former patients. Though the students are not yet adequately prepared to interpret the test information I bring, I have them spend time wrestling with the referral questions and the consequences of whatever recommenda-dons they may bring to the referring physician or attorney. This provides a sometimes-stark awakening to the power implicit in the work of professional psychology and provides opportunity for conversation about Christian virtues when we find ourselves in positions of power.

One of the functional competencies required for psychological training is our ability to select assessment measures with attention to issues of reliability and validity. The importance of this competency becomes dear as students confront the sometimes-monumental impact of their assessment decisions and recommendations. After assessing a patient, a psychologist may make treatment recommendations or testify in forensic settings in a way that alters the patient's life. This makes it essential to understand the connection between rest reliability, validity, and how responsible opinions are formed.

Religious and spiritual topics as assessment domains. Though psychologists value diversity in training, increasing evidence suggests that little or no attention is given to religious and spiritual diversity in most APA-accredited doctoral training programs (Vogel, McMinn, Peterson, & Gathercoal, 2013). Yet, a substantial literature suggests that most people desire having their spiritual values integrated into the therapeutic process (Hodge, 2013). Of interest, while mental health is increasingly gravitating toward integrated health care models, few psychologists or counselors are aware that the largest health care accrediting body in the United States (Joint Commission) requires a spiritual and religious assessment in hospitals and facilities providing addictions treatment, recommending a two-tiered process, which will be described shortly (Hodge, 2013).

Most of the examples offered throughout this article pertain to Christian faith integration and psychological assessment, but it is interesting to note that explicitly Christian integrative programs appear to do a better job in religious and spiritual diversity training than other APA-accredited doctoral programs (McMinn et al., 2013), and not just in Christian religion and spirituality. Balancing a way to discuss religious and spiritual diversity alongside distinctly Christian views is a challenge facing explicitly Christian doctoral programs such as ours, and was a challenge in crafting this manuscript as well. Most of our examples pertain to Christian faith integration, though some consider faith in more diverse contexts.

As part of understanding test development, I have students review literature and test manuals in preparation for three "Roundtable Discussions" that we have throughout the semester. As part of the Roundtable they discuss the normative samples for the assessment tools, evidence for reliability and validity, and ways they might use particular assessment tools in professional practice. The first Roundtable pertains to tests of intellectual ability and achievement, the second to personality assessment, and the third to religious and spiritual assessment. This assures that students early in training have exposure to the vast literature on how to assess religious and spiritual issues. It sometimes surprises students to know how many tests are available to assess various dimensions of religious and spiritual life. The class only affords us time to consider of few of these tests, summarized in Table 2, but I always emphasize to students that many more exist. They also become familiar with important resources to help them evaluate the psychometric properties of religious and spiritual assessment tools (e.g., Hill & Hood, 1999) and consider effective methods for religious and spiritual assessment in clinical practice (Richards & Bergin, 2005).

TABLE 2 Examples of Tests Used in Roundtable Presentations in a
Psycbometrics Class

Test Brief Description Intended Age
 Group

Attitudes toward This 9-itera scale Adults
 assesses
God Scale an individual's
(ATS-9) perceived
 relationship
 with God on two
 scales: 1)
 positive
 attitudes toward
 God and 2)
 disappointment
 and anger with
 God.

Duke Religion This 5-item Adults
Index scale measuring
 religious
 involvement has
 been widely used
 in research
 studies and is
 available in 10
 languages.

RCOPE and Brief The R-COPE (105 Adults
RCOPE items) and Brief
 RCOPE (14 items)
 assess how
 religion is used
 when coping with
 adversity.

Religious A 10-itcm scale Adults
Commitment designed to
Inventory measure
(RCI-10) religious
 commitment, the
 RCI-10. Though
 there are two
 subscales -
 intrapersonal
 and
 interpersonal
 commitment -
 they are so
 highly
 correlated that
 religious
 commitment on
 the RCI-10 is
 best viewed as a
 single
 construct.

Spiritual This is a Adults
Assessment 54-item scale
Inventory- that provides a
 relational
 understanding of
 one's
 relationship
 with God,
 including
 Awareness of God
 and Quality of
 Relationship
 with God.

Spiritual A 24-item scale Adults
Transcendence that considers
Scale Spiritual
 Transcendence as
 a potential
 sixth dimension
 of the
 Five-Factor
 Model of
 Personality.

Test Reference

Attitudes toward Wood, Worthington, Exline,
God Scale Yali.Aten, & McMinn(2010)
(ATS-9)

Duke Religion Koenig& Bussing,2010
Index

RCOPE and Brief Pargament, Koenig, & Perez,
RCOPE 2000; Pargament. Smith,
 Koenig, & Perez. 1998

Religious Worthington et all, 2003
Commitment
Inventory
(RCI-10)

Spiritual Hall & Edwards, 2002
Assessment
Inventory-

Spiritual Piedmont, 1999
Transcendence
Scale

With regard to spiritual assessment in clinical practice, Richards and Bergin (2005) recommend a two-tiered method of assessing religious and spiritual issues. In the first step, an ecumenical assessment, they recommend asking clients/patients some questions about the importance of religion and spirituality in their lives; some examples are found in Table 3. For those clients who identify as religious or spiritual, and are desirous of including the spiritual dimension of their lives in treatment, Richards and Bergin (2005) suggest a more detailed assessment, including using some of the instruments described in Table 2. Also, Hodgc (2013) provides a detailed set of questions that could be used sonality Assessment course. The easiest way for me to do this is by presenting case studies of candidates for ordained ministry. Since 1990, I have worked as a Ministerial Assessment Specialist for several church denominations in my private practice. I administer the MMPI-2, 16-PF, and PAI to these clergy candidates as part of my assessments of their fitness for ordained ministry. Given that these are three of the four major personality assessment instruments that I teach in the course, presenting de-identified cases from my clergy assessment practice offers the students and me some opportunities to integrate Christian faith and theology, as well as church culture (as a form of diversity) with personality assessment. An example of this is a clergy candidate who presents with an attitude of, "I have the truth and you don't" and a belief in God's special favor (along with its resultant sense of entitlement) to a degree that crosses a line into narcissistic pathology. Another example includes a pastor whose crisis of faith manifests as a major depressive episode. Other examples include pastors whose deep Christian faith serves as a protective factor against post-traumatic residuals of childhood traumas (and whose test results are within normal limits).

TABLE 3

Potential Assessment Questions that could be used as part ofan
In-take Questionnaire or Interview

1. As you think about coping with the struggles of life, how
important are your faith beliefs to you?

not important somewhat important very important

2. Do you attend formal religious services?

no occasionally frequently

If so, what is your religious affiliation?

3. Have religious or spiritual influences been hurtful to you in
the past?

no not sure yes

If so, how?

4.Have religious or spiritual influences been helpful to you in
the past?

no not sure yes

If so, how?

5.Are you part of a community of faith?

no not sure yes

6.Would you want spiritual issues to be in our work together
when they seem relevant?

no not sure yes

One meaningful exercise that I do with the class involves sharing with them simultaneously two cases of clergy candidates. Both are male, of similar age, and both were combat veterans in the Vietnam War. As I help the students interpret these candidates' personality assessments, they discover that these candidates' MMPI profiles are radically different from each other. I also share with them how one of the candidates ended up being very successful in ministry while the other one (with the worrisome MMPI) was eventually denied admission to pastoral ministry by his church board. We discuss the nature and dynamics of each clergy candidate's Christian faith, and how those dynamics ultimately seemed to serve as either risk factors or protective factors in that candidate's personality functioning. For those readers of this article who wish to incorporate clergy assessments in their Personality Assessment courses, a rich pool of resources exists in the national network of psychologists who serve as ministerial assessment specialists (as I do). Instructors wanting to try this approach could contact local churches in their community and ask for the contact information of the psychologist who conducts the ministerial assessments for that church's denomination. It is quite possible that the psychologist would be willing to serve as a guest lecturer in the Personality Assessment course (for which the psychologist may benefit by earning CE hours from the presentation, while the students benefit from the Christian integration opportunities from the psychologist's case presentations). If the psychologist does not live locally, a Skype "presentation" could serve as an alternative.

In the Personality Assessment course, I also use case studies from my private practice with non-clergy individuals to illustrate how psychologists can conceptualize cases from a synthesis of personality assessment and Christian faith. For example, I share a client's case history along with her MMPI report. The client was a devoutly Christian woman who had seriously contemplated suicide because her church elders had forbade her to leave her husband. Her interpretation of the bible also led her to conclude that her only way out of her marriage was suicide since he had not been unfaithful to her. Each year when I present this case, the students and I have a rich discussion of how the MMPI findings inform how her personality functioning intersects with her spiritual functioning to create a perfect storm of inner anguish.

When teaching how to use personality assessment to diagnose psychopathology, I also explicitly integrate Christian faith by discussing how some of the early Church fathers such as Richard Baxter and Bishop Butler created spiritual versions of diagnosis, not unlike the DSM in format (Roth, 1998; Talbot, 1998). We talk about how to conceptualize personality assessment and diagnosis from a historically grounded perspective of Christian integration.

Another intersection of assessment and Christian faith that I discuss with my class pertains to the way that Christians as a subculture tend to interpret certain test items in different ways than the standardized population. For example, Duris, Bjorck, and Gorsuch (2007) found that participants who were immersed in a Christian subculture differed from the norm on the MMPI-2 Lie (L) scale on five religiously salient items, as predicted. This finding calls into question the validity of the L scale when interpreting the MMPI-2 profiles of devoutly Christian persons.

Also noted is my impression that, given the large body of research done on the MMPI-2, it is striking to note the paucity of studies that specifically assessed Christians (Rhee, 2010) or other religious groups. In one of these few studies, Sullender (1993) tested clergy candidates with the MMPI-2 and found that that they were generally emotionally healthy, with lower scores than the norm on anxiety and depression, and with higher scores on capacity for responsibility and leadership. However, they were found to avoid interpersonal conflicts and their own negative feelings. Male clergy candidates showed more difficulty in managing anger than the female candidates. Despite these differences, it is also noted that, overall, no adjustments to clinical scales are indicated when interpreting clergy MMPI-2 results because the differences just noted did not create meaningful scale distortions.

Cardwell (1996) tested seminary students and also found them to be well-adjusted overall, with the exception that they seemed to have difficulty expressing anger appropriately. Rhee (20 I 0) provided a cross-cultural perspective in her investigation of the MMPI-2 results of Korean seminary students. She found them to be well-adjusted and with many evident strengths. However, she noted that their F scores were well below the norm, and hypothesized that this may reflect a cultural difference. She further noted that her findings did not replicate those of Duris, et al. (2007) regarding the L scale.

It is notable that there is a paucity of research on how persons from Christian subcultures respond to test items on the MCMI, PAL 16PF, and other personality tests. Other spiritual traditions similarly have not been empirically investigated with these instruments. It would likely be a fruitful topic to bring up in class and invite student discussion for the purpose of raising awareness of how spiritual diversity might affect personality test profiles. Such discussion might also be useful by providing viable dissertation topics for students interested in filling this empirical gap.

Cognitive Assessment

I (Adams) must admit that I was stumped considering how to integrate faith and psychology when I started teaching a Cognitive Assessment class. After all, how does one administer a WAIS in a Christian manner? One solution I stumbled upon emerged as I was reflecting on how the words "test" or "testing" are used in the scriptures. In the NIV, these words are found 95 times. In reflecting on many of those passages, it seemed that most could be organized using the following categories: God testing people, people testing God, people testing people, and people testing themselves. I was struck with how little testing was associated with Satan's .activities, Job's, and Christ's temptations notwithstanding. These and other musings eventually took the form of a brief devotional at the start of class, dealing with an example from one of the above categories, eventually surveying each category by the end of the semester. For example, during the course we wonder at the incredible statement God makes to his people, "Do not be afraid; I have come to test you" (Exodus 20:20)! Or we delight in God's patience and sense of humor displayed with Gideon's tests of God (Judges 6-7). We try to discern why God sometimes invites us to test him (Malachi 3:10) but at other times we are condemned for doing so (78:41). I have asked students, as part of the end-of-semester course evaluation, to rate whether these devotionals were a good use of class time. Over the ten years that I have asked, students have consistently given this course component high marks.

Formal training opportunities. Half of our Cognitive Assessment course is focused on intellectual assessment. An issue that naturally arises near the middle of the course amidst the topics of IQ classifications and etiologies of intellectual disability, is a discussion related to the question, should a Christian value intellectual ability? It leads to an especially probing discussion, which can posit that God values intelligence because the scriptures are clearly written by and for people with sophisticated levels of ability. Then, what is the correlation between spirituality and IQ? Obviously it is not high, since century after century seemingly bright people have perpetrated great evil. Is there such a thing as spiritual retardation and is that related to intelligence? How does intellectual disability affect spiritual maturity or spiritual value? Does acquired brain damage that negatively impacts one's cognitive ability and personality, also impact the soul, and if so, how? How might our cultural values as academically successful persons color how we think about and respond to these difficult questions?

Another topic that I bring up early in the course is the great social injustice that has been caused by IQ testing. Crawford (2013) recently summarized some of these tragedies perpetrated by well-intentioned users of IQ tests, including serving as a basis of forced reproductive sterilization as well as a basis of establishing immigration quotas that favored white European, English-speakers, while shunning eastern European families, many of whom eventually were exterminated in Nazi death camps. But rather than a test-bashing session, I present evidence showing that many of the persons contributing to such policy decisions were upstanding and humanitarian individuals in other areas of their lives, hopefully moving the discussion past the "demon test" position, to one that asks what could have influenced worldviews that made it seem humane to develop and implement such policies that today seem so reprehensible? What might be today's equivalents of such well-meaning but ultimately destructive efforts? What constitutes "fair" or unbiased tests and what values are being assumed in formulating that response? Must a Christian worldview (e.g., imago Dei) collide with a scientific worldview for contemporary test developers, or for clinicians performing assessments? Again, the notions of humility, respect, and the potential for abuse of professional power take center stage. As Crawford succinctly put it, "how we see people affects how we treat people" (2009, p. 1).

Near the end of the course, class time is increasingly spent on test interpretation for common referral questions, using various cognitive measures. Some of the cases I present are assessment referrals from Christian organizations, such as a missionary candidate struggling with language school, bringing the question of a possible selective learning disability in acquiring foreign language. Such a case illustrates how test findings and history can be used to posit the unlikelihood that this candidate will learn to speak Arabic fluently, but also show how uncovered cognitive strengths can open up meaningful ministry roles not previously considered.

Informal training opportunities. Occasionally, unexpected assessment opportunities arise and can provide a rich experience to integrate professional skills, mentoring, and ministry. Most of the 135 mission schools found outside the United States have limited or no on-site, appropriately trained professionals who can consult with a teacher or parent concerned about a child suspected of having a learning disability and/or behavior disorder. Accordingly, there are opportunities for small teams of professionals and trainees to have short-term visits to some of these schools to extend much needed and appreciated diagnostic assessment services. Having engaged in this kind of activity twice, I can attest that it is extremely demanding but rewarding; a model of how practitioners might conduct such an experience has been described (Adams, Shaver, & White, 2003). Two graduate trainees and I usually "hit the ground running" after a day set aside for jet-lag recovery. Two evaluations are scheduled each school-day morning in separate rooms (with me as "itinerate" supervisor and fellow examiner), and each afternoon the students and I meet with parents (first hour), teachers (second hour), and sometimes the student clients alone (a third hour) for interpretive and planning conferences. My students then spend the evening scoring up that morning's evaluations, interpreting the results using discussions amongst ourselves, and then preparing a draft of the reports that will be used for the next day's debriefings. Ten to sixteen full evaluations, plus associated reports and debriefing sessions, are completed in five to eight days, respectively--a grueling schedule. We usually leave a weekend for some rest and relaxation and cultural exposure; even so, it is an intense experience. Nevertheless, there are rich rewards. In addition to the value of puzzling over results from multiple assessments in a concentrated time frame, generating useful recommendations, and communicating this information meaningfully to clients, students are also introduced to a possible venue for pro bono work to which they may be called in their professional futures. Spiritually, I suspect that I have never had a better inkling of heaven than joining a packed worship service during one of these trips, hearing the hymn In Christ There Is No East or West sung enthusiastically in a language I did not recognize and yet feeling one with those singing. Understandably, I have had former students tell me that their time abroad working to exhaustion was remembered as one of the most worthwhile experiences of their graduate training, and one that meaningfully integrated theology. Christian service and professional psychol-ogy--more evidence that [faith] integration "is caught more than taught" (Sorenson, 1994, p. 342). I suspect similar opportunities are available in private Christian schools within easy driving distances of many of our offices.

Projective Assessment

When I teach this course on Projective Assessment, I (Thurston) begin introducing Christian integrative themes on the first day of class with a Rorschach case. The students generally have little knowledge of the Rorschach or how to interpret it at this point. I give the students the Rorschach responses of a woman whose reason for referral involves unexplained physical reactions to an insect bite, a case I adapt from Ganel-len (1996). From this sketchy referral question, and knowing nothing of this woman's background data, we read through her Rorschach responses together, discuss them, and come up with her DSM diagnosis. I deliberately choose this case because the Rorschach protocol is laced with religious imagery. Indeed, on Card I, her first response is "God. This could be a bat.), I ask the students to pause right there and reflect on what might be going on in this woman's internal world to choose "God" as her first verbal reaction to seeing the first card. From there, the students read responses that involve biblical tribulation, the Apocalypse, and other imagery from the Bible. Interspersed with this are bloody images of a dead rabbit on the road, alternating with warm and loving family images. Students eventually gravitate toward the diagnoses of conversion disorder, major depressive disorder, and histrionic and borderline personality traits. At that point, we read this woman's background history together. We discover that she was a member of a Fundamentalist church with which she closely identified, and that her daughter had been killed in a car accident (hence the Rorschach imagery of the bloody rabbits on the road). We read about her long-standing personality rigidity that had led to multiple relational difficulties at home and at work. We discuss at length the personality characteristics that can be associated with one's religious faith. We conclude that for this woman, who was the child of an alcoholic father, joining a Fundamentalist church as an adult likely served an important psychological function to help hold her chaotic internal world together. Unfortunately, that structure involved rigidity that was working against her in several ways. One way was in her relationships, but another was in her Christian faith contributing unconsciously to anxiety and depression (as evidenced in the dark imagery on her Rorschach responses involving Biblical tribulation, and with the associated scores of the blackness of the percepts suggesting depression). Her rigidity of personality functioning also seemed to make it difficult for her to process the trauma of her daughter's death, and her dark religious imagery seemed to be unconsciously entangled in this difficulty.

Later in the Projective Assessment course, when the students have achieved competency in administering and scoring the Rorschach, I have them do practice assessments with volunteers. Last year, one of my students went to a nearby Benedictine monastery and administered the Rorschach to a 70-year-old monk. The student presented this Rorschach case to the class, and we had a rich discussion about the internal world of a man who had spent so many years immersed in the Christian disciplines and living in Christian community. This case was so particularly fascinating from a Christian integration point of view that I plan to suggest to future students in this class that at least some of them do their volunteer testings with monks or nuns. I hope to have the class compare these individuals' responses on the Rorschach, TAT, Rotter Incomplete Sentences Blank, and Figure Drawings to those students' volunteers who were not from these kinds of Christian communities.

Another way in which I weave in some explicit faith integration into my Projective Assessment course is by introducing the students to the Spiritual Themes and Religious Responses (STARR) test (Saur and Saur, 1993). This test consists of 10 picture cards depicting people from various religious faiths and cultures in various religiously themed contexts (e.g., receiving a communion wafer). These people portray universal themes such as solitude, grief, joy, awe, celebration, family relatedness, and death. Clients are asked to tell a story or prayer based on each card; these responses are then analyzed and interpreted in a similar way to the Thematic Apperception Test, only with the added dimension of psycho-spiritual themes. The STARR may be useful for clients who seem to have strong unconscious feelings about organized religion, who are conflicted about their faith, or whose psychological conflicts may be in some way related to deeper religious or spiritual dynamics. For example, the manual for the STARR includes a case study of a man whose stories had a repetitive theme of people praying in a rote, mechanical sense--"going through the motions." At the same time, his stories had recurring themes depicting the characters as depressed. Taken together, these psycho-spiritual themes suggest that this person's depressive tendencies may be manifesting in his relationship with God, which he seems to experience as lifeless and rule-governed instead of enlivened, spontaneous, and nurturing.

In addition to the STARR, students are introduced to another projective test, the Thurston Cradock Test of Shame (TCTS) (Thurston & Cradock O'Leary, 2009). The test consists of 10 picture cards, which depict scenes that could involve shame, and the subject is asked to make up a story about each card. I share TCTS cases with the students and weave the interpretation of these cases with theological concepts of shame as well as psychological shame theories (Thomas & Parker, 2004; Smedes, 1993). The topic of shame is deeply integrative (e.g., Jesus accepting the shame of being mocked, scourged, and then crucified), yet it also permeates the field of psychology (e.g., Erik-son's (1950) developmental stage of autonomy versus shame and doubt; also, Helen Lewis' (1987) notion of shame as a "sleeper" in psychopathology). The themes of shame and guilt, as well as their counterparts, grace and pardon, are woven through the tapestries of both psychology and Christianity. Accordingly, I share with my students a TCTS story that depicts a victim of a hate crime forgiving the offender, despite the victim's feelings of shame about the incident. Using this same TCTS card, others have created stories of the victim of the hate crime killing the offender in retaliation. The striking divergence in these projective stories offers the class an opportunity to contemplate how different people process shaming stimuli, both psychologically and with respect to Christian epistemology. In their book Righteous Religion: Unmasking the Illusions of Fundamentalism and Authoritarian Catholicism, Ritter and O'Neill (1996) connect the rigid attitudes and hierarchy of fundamentalist religions with conditions that perpetuate pathological shame in parishioners. The TCTS can evaluate the possibility of whether such shame is evident in these parishioners, as well as the degree to which a person's TCTS stories contain resolutions to shame that include Christian values such as forgiveness. Integrating this with a psychological perspective of relational psychoanalysis, we can use the TCTS to evaluate the subject's capacity to move through relationships with a healthy rhythm of rupture and repair (Benjamin, 2009).

Clergy Assessment

I (Thurston) teach an advanced elective course on the assessment of candidates for ordained ministry. For this course, the students join me in the consulting room one by one for clinical interviews with clergy candidates who consent to this inclusion. The students assist in the interpretation of personality test results as I mentor them in case conceptualization and report writing skills. Given that the clergy candidates are seeking ordained ministry in Christian churches, it affords students an easy inroad into explicit discussions about the many ways that Christian faith intersects the psychological functioning of these individuals.

I begin this course by resourcing the students on topics such as the clergy assessment process for various church denominations, legal and ethical issues in clergy assessment, and an introduction to the tests that typically comprise the battery of assessments that I use (which currently include the MMPI-2, 16-PF, Sentence Completion Test, four references, and a Personal Data Inventory). I regularly attend the national quadrennial clergy assessment conference for ministerial assessment specialists, sponsored by the United Methodist Church. Delegates of other denominations have also been attending these conferences as they ramp up their own clergy assessment plans. These conferences provide rich resources for me on the current best practices in clergy assessment, including topics such as legal and ethical issues mentioned above. For faculty at other universities who might want to teach a course in clergy assessment, I highly recommend attending these quadrennial conferences.

One other topic that I focus on in the Clergy Assessment course is how psychologists can serve as consultants to churches in matters such as how to help a denomination design its own clergy assessment program. I use specific examples from my own consultant work to discuss how to help construct a clergy assessment program that dovetails with the ethos and customs of that particular denomination. I also share with the students how I have served as a consultant to church boards, which arc trying to use my clergy assessment results to make final decisions as to whether or not to ordain clergy candidates.

Clinical Foundations In-take Training: Religious Assessment

While much of our first-year Clinical Foundations course is related to the basics of psychological intervention, portions of it are related to assessment, such as designing and implementing an intake-interview. One domain that can be assessed during such an interview is spirituality. As Richards and Bergin (2005) point out, by including a religious faith/spirituality assessment within the in-intake process, the therapist then has a fuller understanding of 1) the client's worldview, 2) whether the client's spiritual orientation may have a bearing on the presenting problem, and 3) whether the client's spiritual beliefs may have the potential of being therapeutic for the client and possibly be a basis for actual treatment interventions. Obtaining this kind of helpful information using an intake questionnaire or interview could possibly be achieved by using questions such as those found in Table 3.

Conclusions and Future Directions

A foundational assumption related to psychological assessment is that individual differences exist; if this were not the case, measurement would not only be impossible from a psychometric perspective, logically it would be unnecessary. Human difference is also a basic scriptural tenet, as illustrated by the Pauline notion of different "gifts" given to believers, as well as of different body parts performing their unique functions that when combined, make up the church. A vast literature tells us that for most traits or qualities, a normal curve typically characterizes their distribution in the population. It is this variability that allows assessment tools to gradually acquire the kind of predictive precision that makes them useful in better understanding the nature of a client's problem and with relative efficiency.

It is interesting to note the progression of intended professional assessment competency from practicum to internship, and eventually to independent practice, as portrayed in Table 1. Early on in graduate training the emphasis tends to be on knowledge and skills, such as knowing what makes a test reliable and how to administer it in a standardized fashion. For the two subsequent training stages, one can observe the increasing importance of the Christian virtues of respect, patience, humility, hard work, and extending grace as the examiner applies sophisticated psychometric knowledge and a mastery of testing procedures. Additionally, the growth of the trainee also reflects an understanding of the corrupting power test results can have on us as clinicians. The impact of these Christian virtues is probably most evident in interpreting findings and generating recommendations. While it may be subtle, it is nonetheless powerful that the worklyiew we hold will make the above virtues easier to embrace, predisposing practitioners to make decisions characterized by the ethical pillars of beneficence, non-maleficence, integrity, justice, and respect. Given this progression of responsibility from early training to independent practice, it also makes sense to provide integration training that also reflects a graduated developmental sequence that can be tailored, given the very different spiritual backgrounds students have when they enter the program. This is something we have only begun to implement in the GDCP, but hope to expand in coming years.

One area that needs more professional attention is related especially to spirituality measures. First, it would be helpful to have available a comprehensive review of existing measures that are available for assessing spiritual domains, such as those examples exhibited in Table 2. Such a review would include details about each measure that clinicians might find useful, such as test format, time needed to administer and score, and psychometric background like the existence of norms, as well as test-retest reliability and validity data. That would allow those interested in assessing spiritual areas to know what test options exist, as well as provide useful and necessary information for clinicians choosing among the various options available.

A second domain that needs attention is related to how religious persons' beliefs influence scores on commonly used personality measures. While there is a sparse literature that is sometimes equivocal (e.g., the MMPI-2 L scale found to be elevated with one group of Christians but not elevated with another group--see Duris et al., 2007; Rhee, 2010), there are major gaps in whether non-clinical individuals from some religiously diverse groups may have elevated clinical scales, suggesting pathology simply because of how their religious worldview causes them to interpret some of the test questions. Most clinicians are aware that the cultural heritage of many Latino and African-American persons can influence their test performance, sometimes to a clinically meaningful degree (e.g., Coffey, Marmol, Schock, 8c Adams, 2005; Razani, Burciaga, Madore, 8z Wong 2007). Accordingly, it could be argued that such an adjustment may be warranted for clients of some religious groups. We just do not know the impact various religious backgrounds have on many of the tests, especially personality tests, and filling this void in the literature seems a worthwhile endeavor by those with special interest in the integration of faith and psychology.

Yet another need is for greater attention to be given to creating measures that are not self-report in format. As Gorsuch (1984) and Tsang and McCullough (2003) assert, the majority of existing tools used to assess spiritual dimensions tend to utilize subjective client impressions of how much or how little clients perceive they possess or exercise the trait in question. Supplementing these and newer measures with more objective (operationalized) criteria would allow a comparison between subjective impression and actual behaviors and/or outcomes. That is, it is possible for two clients to have similar scores in their perceived levels gratitude, and yet their overt expressions of gratitude may differ considerably. While client perceptions of and attitudes toward a trait such as gratitude are important to appreciate, like James' pronouncement (2:17), it may be even more important for a therapist to know if behaviors commonly recognized as reflections of gratitude are typically demonstrated when interacting with family, friends, and fellow workers.

Table 2 reports some of the tests of religion and spirituality that are reviewed in our psychometrics course, but it is striking to note that all of these are intended for adults. Though some have studied spirituality of children (e.g., Boyatzis, 2009), it remains an underdeveloped area, especially from an integrative perspective. Scale development is an arduous process, but it appears we need more work done when it comes to assessing religion and spirituality among children and adolescents.

Finally, more effort needs to be extended in creating measures that are sound in assessing positive qualities, such as resilience, gratitude and forgiveness. The testing movement began with and continues to emphasize detecting deficits and pathology. Likewise, assessment efforts by Christian professionals have possibly overemphasized deficits. However, so much of a spiritual and especially Christian perspective highlights restoration, virtues, and other positive qualities. Where are the measures that allow us to assess current strengths and the potential for growth in positive traits and states? It is interesting to conjecture what a positive MMPI-like instrument might look like. Created using groups of individuals with recognized strengths in self-esteem, optimism, courage, fortitude, resilience, and forgiveness, as examples, could questions be generated that would create valid scales to which T-scores could be assigned, to diagnose tendencies to be "healthy" and exert a healthy influence? If valid, such information could have enormous worth in clinical contexts as varied as clergy screening, corporate leadership, marital therapy, and vocational counseling. It is indeed curious to consider the typical testing agenda set forth for a comprehensive assessment. Generally, it is not comprehensive since it seldom includes strength-based foci along with measures primarily designed to detect deficits and pathology. Perhaps, those interested in spanning the gulf between religion and psychology could provide a solid bridge based on psychometrically sound client measures of positive personality qualities.

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Wayne Adams, Mark R. Mcminn, and Nancy Thurston George Fra University

Author Information

ADAMS, WAYNE. PhD. Address: George Fox University, Graduate Department of Clinical Psychology, 414 N. Meridian Street, Newberg, Oregon 97132. Email: wadams@georgefox.edu. Title: Professor. Degrees: PhD (Applied Developmental Psychology) Syracuse University, ABPP in Clinical Psychology. Specializations: Pediatric Neuropsychology.

MCMINN, MARK R.. PhD. Address: George Fox University, 414 N. Meridian Sr., #V104, Newberg, OR, 97132. Title: Prokssor of Psychology. Degree: Ph.D.--Vanderbilr University. Specializations: Integration of psychology and Christianity, technology and practice, positive psychology and the Church.