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Evidence-Based Relationship and Therapist Factors in Christian Counseling and Psychotherapy

R. Scott Stegman, Sarah L. Kelly and T. Mark Harwood

The purpose of this chapter is to enhance the effectiveness of psychotherapy by focusing on evidence-based relationship and therapist factors in the context of Christian psychotherapy. According to Norcross (2002b, 2011), relationship and therapist factors take into account who our clients are and who we are as therapists, as well as how we perceive and interact with one another. Relationship and therapist factors have been found to account for a substantial portion of positive client gains. For example, Horvath, Flückiger and Symonds (2011) found that the therapeutic alliance accounts for a large degree of positive therapeutic gain evidenced by clients. They suggested that the relationship may actually account for a greater degree of change than technique. Of particular relevance to our present chapter, initial studies on matching religious clients with religious therapists suggest that religious and spiritual relationship and therapist factors may further strengthen perceived and realized treatment outcomes (Worthington, Hook, Davis & McDaniel, 2011). Though the impact of relationship and therapist factors has received a fair amount of attention over the last decade, uniquely Christian factors have received much less attention.

To help readers learn how to make the most of relationship and therapist factors in their practice, we provide a general overview of client therapeutic religious and spiritual concerns and preferences, and we attempt to parcel out evidence in support of a Christian integrative approach. We then shift our focus by providing a brief summary of the current research available on religion and psychotherapy relationship and therapist factors. Next, we survey evidence-based variables in the psychotherapy relationship that should be monitored and adjusted to each client so as to maximize the effectiveness of the therapeutic relationship. We also suggest some guidelines on how to consider and leverage a client’s religious commitment in the therapy relationship. Finally, we will offer several practical tips on how to utilize this information in the psychotherapy room.

What to Keep in Mind About Relationship and Therapist Factors

The therapeutic alliance, or bond between client and therapist, is the quintessential common ground shared by most psychotherapies. How and to what extent this alliance affects the outcome of therapy has been the focus of many studies. Horvath et al. include 190 such studies in their meta-analysis. Likewise, Johansson and Jansson (2010) found that measures of helping alliance taken toward the end of therapy correlated well with psychotherapy outcome. Through meta-analytic studies, Horvath et al. found that the strength of the psychotherapeutic relationship tends to increase positively with time. In an earlier meta-analysis of the therapeutic alliance and psychotherapy outcomes among children and adolescents, Shirk and Karver (2003) found positive correlations between therapeutic alliance and psychotherapy outcomes. The findings mirrored those found among adult populations. Across psychotherapeutic modalities, the strength of the therapeutic alliance builds over time. These findings may also suggest that the psychotherapeutic relationship needs to be monitored (perhaps through questionnaires). This can be done throughout the course of treatment in order to track client progress and help alert the therapist, and client, to any potential relational issues that may need to be addressed to ensure the growth of a strong psychotherapeutic bond and its translation into stronger mental health outcomes.

Several factors appear to influence the therapeutic alliance. Empathy has long been acknowledged as a key element in the development of the therapeutic relationship and has received empirical support over the years. According to meta-analytic findings by Elliott, Bohart, Watson and Greenberg (2011), empathy may account for approximately 4% of variance in clinical outcome studies. The American Psychological Association’s joint task force involving Division 29 (psychotherapy) and Division 12 (clinical psychology) also identified several “promising elements” of the therapeutic relationship, including: (a) requesting feedback, (b) repairing alliance ruptures, (c) self-disclosure, (d) management of countertransference, and (e) relational interpretations in psychotherapy (Norcross, 2002a). Other factors that may affect the therapeutic alliance include: (a) severity of client disorder, (b) type of client disorder, (c) client attachment style, (d) therapist use of interpersonal/communication skills, (e) degree of therapist empathy and openness, (f) client-therapist rapport, (g) therapist level of experience, (h) therapist specialized training and preparation, and (i) client-therapist collaboration (Horvath et al., 2011).

In 2011, Norcross convened another joint task force to review meta-analyses of the nine years of subsequent research, which was reported by Norcross and Wampold (2011). Based on the research, the joint task force identified six relationship elements as demonstrably effective: (a) alliance in individual psychotherapy, (b) alliance in youth psychotherapy, (c) alliance in family therapy, (d) cohesion in group therapy, (e) empathy and (f) ­collecting client feedback. Three relationship elements—consensus, collaboration and positive regard—were evaluated as probably effective. Three relationship elements were evaluated as promising but with insufficient research to judge: congruence and genuineness, repairing alliance ruptures, and managing countertransference.

In 2011, Norcross asked the joint task force also to judge the effectiveness of matching variables—an aspect often of great interest to psychotherapists who see Christian clients. They found that at the highest level of evidential base (that is, judged to be demonstrably effective) were four matching variables. Religion and spirituality—along with culture and reactance-­resistance level—were seen as important and demonstrably effective for matching clients’ wishes with treatment. Two matching variables were considered to be probably effective: stages of change and coping style. Two were seen as promising but without enough research to judge definitively: expectations and attachment style.

Overall, some of the aforementioned elements, such as repairing alliance ruptures, are often inevitable, and since they may influence other psychotherapy variables, they should be considered significant. For example, the amount of therapist self-disclosure may vary from client to client, but with resistant clients, appropriate self-disclosure can be used as a helpful way to put the client at ease to build and strengthen the therapeutic alliance. Furthermore, inquiring about the client’s experience and asking for feedback can foster a therapeutic environment of collaboration. These kinds of practices can strengthen the therapeutic alliance, increase the client’s participation and ownership of psychotherapy, and increase the likelihood of positive change.

What’s Faith Got to Do with Client-Therapist Factors?

In this section, we set the stage for a Christian integrative approach to enhancing relationship and psychotherapist factors by providing a brief general review of the research on client religious and spiritual concerns and preferences, as well as introducing the unique needs of Christian clients. We dig further into the literature to bring attention to what research has shown that clients actually want out of psychotherapy regarding issues of faith. We also present a snapshot of research that has examined the impact of matching clients and therapists based on religious factors.

What psychotherapists know. When it comes to working with religious and spiritual clients—especially Christian clients—research suggests that we may not know as much as we might hope. For example, Hage, Hopson, Siegal, Payton and DeFanti (2006) surveyed psychology professionals across numerous settings to determine the amount of training they had received in the area of religion and spirituality. They learned that these professionals generally obtained little training in these matters. Even though Hage et al. did not focus on Christian training programs, in which trainees may receive more training on these topics than in secular programs, this nonetheless remains an important finding. For example, if we take a closer look at the membership rosters of prominent Christian counseling and psychology organizations, we find that a significant number of members are from non-Christian programs like the ones surveyed by Hage and colleagues. Moreover, at a recent symposium at the Christian Association for Psychological Studies (CAPS), a group of highly regarded Christian educators concluded that a wider range of competencies in Christian counseling and psychology programs is needed to push these fields forward.

We hope, of course, that Christian psychotherapists are sensitive to religious and spiritual issues that might be facing clients. In general, O’Connor and Vandenberg (2005) found that secular psychotherapists tend to pathologize the religious beliefs of their clients. When these beliefs were understood to be part of a religious system, clinicians rated the beliefs as less pathological than those of clients who were not seen against a recognized religious membership backdrop. Furthermore, religious beliefs that varied from the most familiar belief systems of the United States were identified as more pathological than those associated with mainstream...