Christian clients' preferences regarding prayer as a counseling intervention.Spirituality has increasingly become a consideration for mental health practitioners. As a result, spiritual interventions, including prayer, are now more frequently used in counseling. However, no research has explored Christian clients' expectations regarding prayer in counseling. This study surveyed first-visit Christian clients and their therapists to ascertain client expectations and therapist beliefs and practices. Analysis with two sample t-tests with unequal variances, one-way analysis of variance, simple linear regression, Pearson correlations, and Fisher's exact tests indicated that (a) 82% of clients desired audible prayer in counseling; (b) they preferred that therapists introduce the subject of prayer; (c) they had strong expectations that prayer would be included in counseling; (d) they wanted counselors to pray for them outside of session; (e) religious conservatives had higher expectations for prayer than did liberals; (f) clients with prior Christian counseling had higher expectations of prayer than did clients without. Research implications are discussed. ********** Spirituality has been increasingly recognized as important in mental health practice (Miranti & Burke, 1995; Wade & Worthington, 2003; West, 2004). Half of mental health professionals claim some type of religious affiliation, believe that spirituality is personally relevant, and value personal prayer (Bergin & Jensen, 1990; Carlson, Kirkpatrick, Hecker, & Killmer, 2002; Shafranske & Malony, 1990). Perhaps as a result, many mental health professionals consider spirituality to be important to people's well-being, including their clients' (Decker, 2007; Genia, 2000; Miranti & Burke, 1995; Wade & Worthington, 2003;). In fact, prayer is the most frequently used spiritual intervention by Christian counselors (Sorenson & Hales, 2002; Wade & Worthington, 2003). Even practitioners working in secular settings regularly incorporate prayer into their practices in some way (Ball & Goodyear, 1991; Marsden, Karagianni, & Morgan, 2007; Yoon & Black, 2006). For instance, such providers believe that praying for a client is appropriate, although most believe that praying with a client is inappropriate (Carlson et al., 2002; Gubi, 2004; Shafranske & Malony, 1990). Many clients also want their religion or spirituality included within the context of counseling (Rose, Westefeld, & Ansley, 2001), perhaps because around 80% of the US population believes in God (Gallup, 2007) and the power of prayer (Princeton Survey Research Associates, 2003). Christian clients, in particular, expect prayer to be included in Christian counseling (e.g., Belaire & Young, 2002). Because sensitivity to clients' expectations helps build the therapeutic alliance, which in turn contributes to positive outcomes (Horvath & Symonds, 1991; Kim, Ng, & Ahn, 2005; Strauser, Lustig, & Donnell, 2004), methods for including prayer in counseling with some clients need to be examined. Important to this examination is determining client expectations about prayer in counseling; research is currently lacking about such expectations. This study rectifies that lack by surveying primarily Christian clients about their preferences regarding prayer in counseling. It further surveys their therapists about their beliefs and prayer practices in order to determine whether therapist factors are related to client expectations. PROBLEM BACKGROUND Historically, religion and psychology have been mutually exclusive disciplines, each field relying on competing theoretical assumptions (Wolf & Stevens, 2001). As indicated above, this situation is changing, and spiritual issues have more recently been deemed worthy subjects of study and research within mental health fields. "Religious or Spiritual Problem" was added to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), and studies have linked people's spirituality with their mental health and clients' spirituality with effective psychotherapy (e.g., Gordon, Feldman, Crose, Schoen, Griffin, & Shankar, 2002; Wade & Worthington, 2003). However, a review of the literature from the last 20 years indicates that the practice of spirituality in the practitioner's office has been somewhat controversial. While some mental health practitioners integrate spiritual practices into counseling practice, some professionals do not value the importance of spirituality (Bergin, 1980; Bishop, 1992; Gubi, 2004); others value its importance, but do not believe that spiritual issues should be included in psychotherapy (Gubi, 2004); others who believe that spirituality should be given a place in the counselor's office lack the training necessary to do so effectively (Carlson et al., 2002; Eriksen, Marston, & Korte, 2002; Richards & Bergin, 2002; Shafranske & Malony, 1990). Ethical, multicultural, and developmental perspectives challenge practitioners to rectify the controversies. Ethical mandates now necessitate respect for clients' spiritual beliefs (ACA, 2005; APA, 2002; CACREP, 2001), and guidelines that have delineated harmful interventions, harmful countertransference, and harmful faith should assist with implementation (Case, 1997; Curtis & Davis, 1999; Genia, 2000; Lovinger, 1996; Mageletta & Brawer, 1998; Pargament, 2002; Richards & Bergin, 2002; Spero, 1982). Further, principles related to knowledge, skills, and awareness that are applied when working with those from different racial and ethnic cultures may also be applied to clients with particular religious or spiritual beliefs (Genia, 2000; Worthington, Kurusu, McCullough, & Sandage, 1996). In addition, some guidelines have been established to help clinicians match interventions with clients' spiritual developmental stages (Fowler, 1986; Griffith & Griggs, 2001; Worthington, 1989). Specialty fields have also evolved that offer guidance to practitioners. For instance, within the Christian counseling specialty, studies have determined what spiritual techniques are used by clinicians-evaluating the client's religious background, recommending religious books, and praying with a client are among those used with the greatest frequency (Ball & Goodyear, 1991; Finney & Malony, 1985a, b, c; Moon, Bailey, Kwasny, & Willis, 1991; Wade & Worthington, 2003; Worthington et al., 2001). THE CURRENT STATE OF RESEARCH ON PRAYER IN COUNSELING A great deal of literature exists on the subject of spirituality and counseling (e.g., Gubi, 2004; Holeman, 1999; Kraus, 2003: Pargament, 2002). A large body of literature also exists on the subject of prayer (Finney & Malony, 1985a, b, & c; Hood, Morris, & Watson, 1987; Schneider & Kastenbaum, 1993). However, in a 10-year review of research on religion and psychotherapeutic processes and outcomes, Worthington, Kurusu, McCullough and Sandage (1996) concluded that few studies have focused on "the role of religion in clients' lives during their counseling" (p. 451, italics added). The subject of prayer as psychologically helpful or as an intervention in psychotherapy has received even less attention (Finney & Malony, 1985a; Gubi, 2004; Hood, Morris, & Watson, 1987; Poloma & Pendleton, 1989). However, a historical review of the literature that does exist is included below. Studies on Prayer in Relation to Psychology or Psychotherapy A body of research addresses prayer's relationship to psychology or psychotherapy. For example, one study determined that religious beliefs played a positive role in achieving mental health (Gordon et al., 2002) and another determined that meditative prayer was moderately related to quality of life (Poloma & Pendleton, 1989). Butler, Stout, and Gardner (2002) determined that the use of prayer among Christian spouses increased a feeling of being emotionally validated by the spouse and increased partner empathy. Fouque and Glachan (2000) found that survivors of sexual abuse who received Christian counseling that included the use of prayer and scriptures perceived the overall outcome of counseling negatively. Frequency of Use and Acceptance of Prayer Surveys of secular and Christian mental health professionals have begun to establish the frequency of use and acceptance of prayer as a counseling intervention (Ball & Goodyear, 1991; Carlson et al., 2002; Gubi, 2004; Shafranske & Malony, 1990; Sorenson & Hales, 2002; Wade & Worthington, 2003; Worthington, Dupont, Berry, & Duncan, 1988). For instance, Sorenson and Hales (2002) discovered that 30% of Christian therapists pray with clients during sessions. In Worthington, Dupont, Berry, and Duncan's (1988) study, therapists reported using in-session prayer in 32.5% of sessions, although it is unclear the degree to which their findings would be applicable today. Further, these researchers did not distinguish between praying with a client and telling the client that the therapist prayed privately for the client. Other research corrected that problem. For instance, in an older study, Shafranske and Malony (1990) determined that 24% of secular clinical psychologists prayed privately for clients, and seven percent reported praying with clients. More recently, Wade and Worthington (2003) found that only 11% of therapists in secular agencies thought that praying with or for a client was appropriate, while the large majority of counselors in Christian counseling organizations believed praying with or for a client was appropriate (78% in Christian agencies and 100% in Christian private practices). In fact, praying with or for a client was the most frequently used religious intervention in Christian agencies, but the least used spiritual intervention in secular agencies. These researchers, however, did not assess who brought up spiritual issues, or initiated prayer; what the client's expectations were related to spiritual interventions, including prayer; or whether prayer was audible or silent. More recently, Gubi (2004) surveyed 578 accredited counselors in England to determine the frequency of use of various prayer interventions. Eleven percent had prayed overtly with a Christian client, 37% had prayed for guidance during a counseling session without the client's knowledge, 49% had prayed for a client away from the client's presence, and 51% had prayed as a means of preparing themselves to work with clients. Usefulness of Prayer in Counseling Since 1957, only two empirical studies have been conducted to determine the usefulness of prayer as an adjunct to counseling. Finney and Malony (1985b) evaluated nine clients to determine whether contemplative or meditative prayer was associated with improvement in psychotherapy. Results indicated weak support for prayer's helpfulness to the counseling process. Connerley (2003) conducted a double-blind study of the effects of distant intercessory prayer as an adjunct to psychotherapy with depressed outpatients and concluded that intercessory prayer can be useful. Intercessory prayer had the strongest effects on the cognitive symptoms of depression and the weakest effects on somatic-behavioral symptoms. Client Desires Ripley, Worthington, and Berry (2001) indirectly explored client expectations of prayer by conducting the only published study to date on potential clients' desires for similarly religious or dissimilarly religious therapists. They found that participants with low-moderate religiosity did not care if their counselor was a Christian or non-Christian. Highly religious respondents did not necessarily seek a highly religious therapist as much as they rejected a less religious one. Summary Polls and surveys indicate the high value that the general population, including psychotherapists, place on spirituality and prayer. Research has also begun to demonstrate the usefulness of incorporating the spirituality of clients. And theory literature suggests ways to integrate spirituality with psychotherapy. Integrating spirituality and psychology is widespread among Christian counselors, among whom prayer is the most commonly used spiritual intervention. However, most studies that have explored the use of prayer have not defined whether in-session prayer was audible or silent. Nor have these studies established client expectations related to the use of prayer in psychotherapy, or whether clients want themselves or the counselor to initiate in-session prayer. This study aims to rectify these lacks in order that prayer may be used more skillfully as a counseling intervention and in order to protect clients from insensitivity or unethical use of prayer by both Christian and secular therapists. METHODS Research Design and Questions The current study was descriptive and correlational, surveying a convenience sample of clients seeking counseling with Christian counselors and each of their counselors. The research asked: What are the preferences of clients concerning the intervention of prayer at faith based counseling agencies? Are there differences between client religious affiliation groups in client prayerfulness and client expectations regarding prayer? Is there a relationship between therapist prayerfulness and their clients' expectations regarding the use of the following five prayer related interventions-therapist intercessory prayer, silent in-session prayer by the therapist, audible in-session prayer by either the therapist or the client, prayer related homework, and who initiates dialogue about prayer? Is there a relationship between client prayerfulness and client expectations regarding prayer related interventions, as listed? Are there relationships between therapist use of prayer related interventions and their clients' expectations of prayer related interventions, as listed? Participants Surveys were distributed to adult clients (N = 165) and their therapists (N = 32) at three agencies, one church counseling center, and six private practices in one large and one medium sized city in a southwestern (non-Bible belt) state. Counselors were licensed (n = 30) or interning (n = 2) and were selected because they advertised themselves or were known as Christian counselors. Snowballing strategies helped to identify Christian counselors. All first time clients at these sites were asked to complete the surveys at the same time as they were completing other intake information, prior to their first counseling session. Approximately 52% of clients completed the surveys. Clients. Sixty four percent (n = 106) of the clients were female, and 36% (n = 59) were male. Of the 94% (N = 155) reporting age, ages ranged from 18 to 77 years old (M = 40.2 years, SD = 13.3). Clients were also grouped according to age to determine whether differences existed between the groups. Twenty nine percent (n = 45) were 18-29 years of age, 22% (n = 34) were 30-39 years of age, 33% (n = 51) were 40-54 years of age, and 16% (n = 25) were 55 years of age or older. Of the 99% (N = 164) reporting on ethnicity, 81.8% (n = 135) were Caucasian, 8.5% (n = 14) were Latino-American, 2.4% (n = 4) were African-American, 2.4% (n = 4) were Asian American, 1.8% (n = 3) were Native American, 1.2% (n = 2) were Middle Eastern, and 1.2% (n = 2) reported "other." Of the 99% (N = 163) reporting on previous counseling, 56% (n = 91) had not received prior Christian counseling, and 44% (n = 72) had received prior Christian counseling. Of the 94.5% (N = 156) reporting religious affiliation, 42% (n = 69) were non-denominational/evangelical, 28% (n = 47) were mainline Protestants, 8% (n = 13) were Catholics, 7% (n = 12) were Baptists, 2% (n = 3) were charismatic/Pentecostal, 1% (n = 1) were Jewish, and 7% (n = 11) listed "other." Therapists. Sixty-six percent (n = 21) of the therapists were female, and 34% (n = 11) were male. Of the 91% (N = 29) reporting age, ages ranged from 27 to 72 years of age (M = 50.1; SD = 11.4). Seventy eight percent (n = 25) were Caucasian, 12.5% (n = 4) were Latino-American, 3.1% (n = 1) were Asian American, 3.1% (n = 1) were Middle Eastern, and 3.1% (n = 1) were African American. Religious affiliations were as follows: 56.25% (n = 18) non-denominational/evangelical, 34.4% (n = 11) mainline Protestant, 6.25% (n = 2) charismatic/Pentecostal, and 3.1% (n = 1) Catholic. The mean years in practice were 11.4 (range = 1 to 29; SD = 8.8; evenly spread across number of years). Procedures After Institutional Review Board (IRB) permissions were obtained, calls were made to identified counselors to ascertain their willingness to participate. Then, the Prayer Survey, the Brief Therapist Prayer Survey, an informed consent form for clients, an informed consent form for therapists, a survey site permission form, and a brief letter of instruction were mailed to those who were willing, along with a large return envelope. Client surveys were completely anonymous, except that they identified their therapist on the survey. Therapists wrote their names on their surveys. This allowed correlations between the data provided by the therapist and their clients. All completed client surveys and informed consent forms remained stapled together and were placed in an envelope for return to the first author. Four clients declined to participate. Signed Brief Therapist Prayer Surveys and therapist consents were placed in a separate envelope. Surveys were either mailed to or personally collected by the first author. Participating counselors were paid $25 or $50 for their efforts, depending on how late in the study they began their participation. Secretaries at the researcher's agency were given $25 or $50 gift certificates to local restaurants, depending on whether they were the only secretary in the agency or if they worked with others. The researcher collected data from the sites throughout a four-month period. In order to increase return rates, the researcher made calls to the counselors and secretaries and visits to the sites to answer questions and remind participants of the procedures. Instrumentation Two instruments were created for the current study: The Prayer Survey for clients and The Brief Therapist Survey for therapists. Because the first author created both surveys, no reliability or validity data currently exists, although substantial efforts were made to achieve face validity. The Prayer Survey for client participants. The content of each survey item was justified either by the literature or by an existing gap or lack of information in extant research. Except for demographic information, all survey items used a seven-point Likert-scale. Items one through three constituted a "prayerfulness index." Because it seemed likely that the degree of both client and therapist prayerfulness might impact their expectations and/or choices regarding prayer in counseling, survey items one through three elicited information related to personal prayer habits and beliefs. Also, because The Brief Therapist prayer survey contained the same prayerfulness items, the mean scores on these three items could be totaled within the two groups and the results could be compared. Items one through three were: "I include prayer in my daily life," "I pray with other people" and "I agree that prayer is natural and spontaneous communication with God who is loving and personal, and prayer indicates my desire to surrender to God's will." Items four and five related to client preferences regarding who should bring up the subject of prayer, the counselor or the client. Information gleaned from answers to these questions was thought necessary to avoid imposing counselor values on clients. Items four and five stated: "I would like my counselor to be the one who brings up the subject of prayer during my counseling sessions," and "I would like to be the one who brings up the subject of prayer during my counseling sessions." Items six through thirteen asked clients what types of prayer they would like used as counseling interventions. Specifics about client expectations seemed necessary because of current controversies about whether it is ethical to pray with clients and because often previous studies have not indicated specifics about how prayer interventions were used. Items six through nine were: "I would like my counselor to pray for me outside of my counseling sessions," "I would like my counselor to pray silently for me during my counseling sessions," "I would like my counselor to assign prayer-related homework," and "I would like audible prayer to be included at either the beginning or end of my counseling sessions." If clients answered "yes" to item nine, they then were asked to specify their preferences related to audible prayer by answering the following items: "I would like my counselor to be the one who prays audibly," "I would like to be the one who prays audibly," "I would like to take turns with my counselor in being the one who prays audibly," and "I would like the counselor to feel free to stop at any time during the counseling session and suggest audible prayer." Demographic data on The Prayer Survey duplicated standard items of interest on surveys. Information regarding gender, age, participation in prior Christian-based counseling, ethnic identification, and self identified religious affiliation was solicited in order to be able to fully describe the research sample and do comparisons between groups. Questions on the Prayer Survey were fine-tuned in conversation with faculty at the university and counseling staff members at the first author's counseling agency. A pilot study was conducted with 10 of the first author's ongoing clients and with nine licensed therapists at the first author's agency. Participants in the pilot study were asked to offer input for incorporation into the final survey regarding the surveys and their experience of taking the survey. The Brief Therapist Survey. A brief survey that paralleled the client survey as much as possible was developed for participating therapists in order to explore the relationship between those therapists' beliefs and practices and the clients' beliefs and expectations. As mentioned above, items one, two, and three on the therapist survey were identical to the first three items on the client survey. The therapist survey paralleled the client survey in six other questions, altered to assess therapists' prayer intervention practices and beliefs. The items included were: "I pray silently for clients outside of session," "I pray silently for clients during session," "I pray audibly for clients during session," "I think that the counselor should be the one who brings up the subject of prayer during counseling sessions," "I think that the client should bring up the subject of prayer during counseling sessions," and "I assign prayer related homework." Demographic items on the therapists' survey duplicated standard items of interest on surveys, items needed to fully describe the research sample. Therapists were asked information related to gender, age, ethnic identification, religious affiliation, and number of years in practice. RESULTS AND DISCUSSION Eighty-Two Percent of Clients Desired Audible Prayer Means, standard deviations, 95% confidence intervals, and frequencies of responses were computed for clients and therapists on all Likert-items (see Table 1). Most impressive was the degree to which clients desired audible in-session prayer. Of the 98.2% (N = 162) of clients who answered this question, eighty-two percent (N = 133) scored from 3 (Sometimes but Infrequently) to 7 (Always) [6.7% responding with 3 (N = 11), 15.8% responding with 4 (Occasionally) (N = 26), 7.3% responding with 5 (Often) (N = 12), 9.1% responding with 6 (Almost all the time) (N = 15), and 41.2% responding with 7 (N = 68). Also noteworthy was that therapists scored higher than clients did on all parallel survey items except two, indicating their greater commitment to prayer interventions than clients expect for themselves. In order to explore who would be more likely to want audible prayer, answers on the relevant items were recoded. Almost never and never scores were recoded "no," and other scores were recoded "yes." Exploratory Fisher's exact tests were used to determine significance of differences. Among the clients who would be less likely to want audible prayer were those who had not received prior Christian counseling, Catholics, and religiously liberal respondents. Differences were significant between the prior and no prior Christian counseling groups (p = .011) with 91% (n = 64) of those who had prior Christian counseling wanting audible prayer and 76% (n = 68) of those who had had no prior Christian counseling wanting audible prayer. Differences were also significant between religious affiliations groups (p = 0.001). Ninety four percent (n = 64) of nondenominational/evangelicals, 92% (n = 11) of Baptists, 83% (n = 39) of mainline Protestants, 100% (n = 3) of charismatic/Pentecostals, 58% (n = 7) of Catholics, none of the Jewish group, 36% (n = 4) of "Others" desired audible prayer. After eliminating from computations the Jewish and Other categories due to low numbers and heterogeneity and collapsing nondenominational/evangelicals and charismatic/Pentecostals due to their similarities, differences were still significant (p = 0.01). Post hoc 2 x 2 cross-tabulations among these groups, using a Bonferroni-corrected significance level of 0.005 (for 10 comparisons), showed that Catholics and non-denominational/evangelical clients were significantly different from each other in the rate at which they desired audible prayer (p = 0.003). Religious affiliation groups were also recoded into "conservative" (nondenominational/evangelicals and charismatic/Pentecostals; n = 83; 52%) and "liberal" (Mainline Protestant, Catholic, and Jewish; n = 60, 36%) and compared. Differences were significant (p = 0.01) with 94% (n = 78) of the conservatives desiring audible prayer and 77% (n = 46) of the liberals desiring it. Also, although not a significant difference, 24% (n = 14) of the males and 14% (n = 15) of the females said "no" to audible prayer. These differences between groups were evident on survey items beyond audible prayer as well. Those who had received prior Christian counseling scored higher on twelve of thirteen survey items (prior M range from 3.9 to 6.3; no prior M ranged from 3.3 to 6.0) and the prayerfulness index (prior M = 16.2, no prior M = 14.7). Using two-sample t-tests with unequal variance, the differences were found to be significant on the prayerfulness index (t = 2.71, p = .01) and three items (range of t values 2.15 to 2.76; range of p = .01 to .03). Differences between religious affiliation groups were also noted, with Catholics and Baptists scoring lower and non-denominational/evangelicals scoring higher than other groups on most items. A one-way analysis of variance was conducted to determine the significance of the differences, using groups collapsed into Protestant, Catholic, non-denominational/evangelical, and Baptist; p-values for post-hoc t-tests were then Bonferroni-corrected. Statistically significant differences were found on nine items and the prayerfulness index (F ranges from 2.7 to 10.49, p ranges from = .0001 to .04). Differences were significant between Catholics and the other groups on several items, and between Protestants and nondenominational/evangelicals on one item. Differences also existed when the four religious affiliation groups were further collapsed into conservative or liberal groups, with religiously conservative clients scoring higher (prayerfulness M = 16.3; item M ranged from 3.6 to 6.5) than liberal clients (prayerfulness M = 15.4; item M ranged from 3.6 to 6.2) on the prayerfulness index and on 11 of the 13 items. Using a two-sample t-test analysis with unequal variances, differences were determined to be significant on six items (t = 2.1 to 3.2; p = .01 to .03; see Table 2). Although no prior research has explored these differences, they are in the expected direction. For instance, clients with prior Christian counseling are more likely to have experienced therapist use of prayer in counseling and therefore might be expected to more highly value its inclusion; they might also experience greater comfort with spiritual interventions more generally as a result of their prior experiences. Further, regarding higher conservative desires for prayer, Worthington and Gascoyne (1985) found that conservatives more than liberals expect greater use of religious interventions such as biblical principles (e.g., forgiveness) and quoting of scriptures. Also, conservatives interpret the Bible more literally than do liberals and therefore would be more likely to abide by biblical injunctions to pray with other people (e.g., James 5:14) or to pray without ceasing (e.g. Ephesians 6:18). Finally, nondenominational/evangelicals, Baptists, and charismatic/Pentecostals would be expected to desire prayer interventions more than Catholics or for similar reasons, as these groups are generally more religiously conservative than Catholics. Clearly, regardless of differences among groups, at least a majority and in some cases almost all Christian clients of Christian mental health providers desired and expected audible prayer to be part of counseling services. Yet some authors express concerns that praying audibly with clients risks confusion of boundaries (Richards & Bergin, 1997). Therefore, to preclude ethical violations, additional training and education regarding assessment and appropriate use of audible in-session prayer may be needed for Christian and other counselors who see the benefit of praying with clients. Also, because therapists state that they pray audibly with clients more frequently (M = 5.5; SD = 1.3) than clients report wanting it (M = 4.9; SD = 2.19), therapists may do well to assess the frequency of audible prayer desired by the client. This is especially true because even though clients "Often" (M = 5.4; SD = 1.67) include prayer in daily life, they only "Occasionally" (M = 3.9; SD = 1.72) pray with other people. Perhaps, this accounts for the fact that clients indicated that counselors should "Often" (M = 5.7; SD = 1.33) be the ones to pray audibly. Further, it would seem that secular counselors of Christian clients would need to more frequently honor their clients' desires to pray audibly, and Christian counselors would need to honor the desires of those who do not wish to pray audibly. In any case, counselor assessment of the client's prior experience with Christian counseling and the client's religious affiliation and beliefs may also help to anticipate a client's desire (or lack of desire) for prayer related interventions. Therapists Report Greater Use of Audible Prayer Than in Other Studies The present study determined that Christian counselors in the sample "Often" to "Almost Always" (M = 5.5; SD = 1.3) prayed audibly with clients. In fact all of the counselors reported praying either with or for clients. Previous research indicated that 30% to 66% of Christian counselors prayed with or for clients (Sorenson & Hales, 2002; Wade & Worthington, 2003; Worthington et al., 1988). The differences may be accounted for by the fact that the other studies did not specify whether the counselors prayed audibly, and therapists in the other studies did not necessarily clearly advertise themselves as Christian counselors. Also, Wade and Worthington (2003) counted the number of sessions in which prayer with or for clients was used, while the present study merely asked for an estimate of how often therapists prayed with clients. Clients Have High Expectations of Prayer Beyond the high desire to have counselors pray audibly with them, clients also strongly desired to include a range of prayer interventions in counseling. Client means on expectations of all prayer interventions measured by the survey items were high. They almost always responded with at least "Occasionally" (9 items) and answered "Often" (means range from 3.6 to 6.1 out of a possible 7) or above on six of 13 items. This implies that a client population attracted to counselors advertising themselves as Christian expected prayer to be part of their "therapeutic" lives, not just their personal lives. These results may pose no problems for Christian counselors; however, secular counselors may find themselves over-challenged by the expectations for prayer among Christian clients. Although most highly religious clients may not want counseling from a therapist who is religiously different from them (Worthington & Gascoyne, 1985; Worthington et al., 1988), insurance and other realities do bring Christian clients into the offices of secular counselors. Further, research has determined that many clients want to discuss religious or spiritual issues even in the context of secular counseling (Rose, Westefeld, & Ansley, 2001). Therapist Use of Prayer Interventions Higher Than Client Desires for Them The results indicate, however, that some caution should be exercised by Christian counselors who wish to integrate prayer interventions. That is, therapists scored higher (prayerfulness M = 18.6; item M ranged from 4.0 to 6.7) than clients (prayerfulness M = 15.4, item M ranged from 3.8 to 6.1) on eight of the nine items that were ranked by both groups. This means that therapists' use of prayer interventions was greater than client desires for the interventions. As with high therapist mean scores on the audible prayer item, high therapist scores can be accounted for by considering the study design, which was to include only therapists who advertised themselves as Christian counselors. Presumably, these therapists would be skilled in the use of interventions valued by the Christian faith, including prayer. Because such therapists may be likely to practice such interventions daily, they may be more prepared to use them than the client would be to receive them. Whatever the reasons, the disparity between the mean scores of clients and therapists reminds therapists to assess client expectations rather than imposing their own expectations. The one exception to therapists scoring higher was the item that asked whether the counselor should pray for the client outside of session. Therapists answered between "Often" and "Almost all the time" (M = 5.5; SD = 1.14), and clients rated this item at "Almost all the time" (M = 6.0; SD = 1.51). Apparently, clients attracted to counselors who advertise themselves as Christian want the counselor to pray for them outside of session more than therapists have been inclined to. Therapists to Introduce the Subject of Prayer Clients more often felt that the therapist, not the client, should "Often" (M = 4.9; SD = 1.90) introduce the subject of prayer. Similarly, both clients and therapists in this study believed that clients should only "Sometimes" to "Occasionally" (M = 3.8; SD = 1.81) bring up the subject of prayer. These findings confirm the conclusions of Carlson, Kirkpatrick, Hecker, and Killmer (2002) that clients prefer that counselors should be the one to bring up the subject of spirituality. Stating that this opinion was contrary to conventional wisdom, these researchers quoted one participant in their study who said, "If we don't at least let clients know that we are willing to talk about their spiritual lives if they feel it would be helpful to therapy, then what we don't say is in effect telling them that it is not ok to talk about these things" (p. 168). One might further conclude that conducting a spiritual assessment within the overall assessment at the beginning of counseling would be a way to clearly indicate the counselor's openness to including spirituality in counseling. Client Prayerfulness Related to Client Expectations of Prayer Interventions Client prayerfulness was related to client prayer expectations. Pearson correlations were used to determine the relationship between client prayerfulness and client means on six prayer related interventions. Client prayerfulness was moderately related to client expectations on all six prayer-related interventions. (range of r from .40 to 58; p = .0001 on all correlations). The correlation between client prayerfulness and client expectations of prayer interventions is expected. That is, those clients who incorporate prayer in their daily lives individually and with others would be more likely to desire it in the counseling room. Relationship between Therapist Practices and Client Expectations Significant, though negligible, relationships were found between therapist beliefs and practices and client expectations. A simple linear regression analysis was conducted on the six items answered by both clients and therapists. Client expectations about three prayer interventions ("Counselor should bring up prayer," "Counselor should assign prayer homework," and "Client desires/therapist uses audible prayer in session") were significantly correlated with therapist use of these same interventions (p = .001 to .01), however, the correlations were very low (r2 = .04 to .11). Although no previous research has been conducted that correlates client desires for and therapist use of prayer interventions, it is not surprising that there is some relationship. That is, the therapists in the sample advertised themselves as Christian counselors, and clients may expect prayer interventions to be included in Christian counseling. Results of Other Exploratory Analyses Age. Exploratory analyses were conducted to examine the possible influences of demographic differences. In addition to the differences noted above with respect to prior counseling and religious affiliation (including our recoding to conservative and liberal groups), significant differences were discovered between the means of the client survey items for age and gender. Age was recoded into four categories (18-29, 30-39, 40-54, and 50+) The youngest group, ages 18-29, scored the lowest on the prayerfulness index and nine of the survey items. The 30-39 age groups scored the highest among the four groups on the prayerfulness index and five items. The next highest scoring group was the 40-54 group, which scored higher than other groups on five items. Results of exploratory ANOVAs indicated that differences were significant on "I include prayer in my daily life" (F = 3.5, p = 0.02) and on "I would like my counselor to pray for me outside of my counseling session" (F = 3.2, p = 0.02). Bonferroni post hoc corrections of p-values determined that differences on the daily prayer item were significant between the 18-29 (M = 4.7) and 30-39 (M = 5.7) age groups (p = 0.04) and on the item that rates the client's preference for the counselor to pray outside of session between the 18-29 (M = 5.6) and 40-54 (M = 6.4) age groups (p = 0.04). Using the Pearson correlation, exploratory results indicated a weak correlation between age and the prayerfulness index (r = 0.14, p = 0.09), "Prayer is included in private life" (r = 0.19, p = 0.02), and "Counselor should pray outside of session" (r = 0.21, p = 0.01), with increases in prayerfulness and prayer expectations as age increases. In the researchers' experience, older clients sometimes value prayer more highly than younger clients, and therefore it is not surprising that the younger group would score lower than the other groups on some of the items, although the lower scores for the oldest group were surprising. Therapists may thus do well to demonstrate special sensitivity to the younger age group, as they may be less likely to welcome prayer interventions, while avoiding stereotypes of older people as more spiritual. Gender. Female clients scored higher (item M ranged from 3.5 to 6.2) than males (item M ranged from 3.5 to 5.9) on eleven of thirteen items and on the prayerfulness index (female M = 15.9; male M = 14.6). A two-sample t-test with unequal variances indicated that these differences were significant on the prayerfulness index and on five items (p ranged from = .01 to = .05; t ranges from 1.99 to 2.29). Considering that two-thirds of both the therapist and client participants were female, it may be that females are more open than males to counseling itself and are thus also more open to experiencing any interventions that can facilitate effective counseling, including prayer interventions. To the extent that these results indicate greater spiritual sensitivity among females, the results are also not surprising. Gaston and Brown (1991) state, Since people assign feminine traits to a religious person and masculine traits to a non-religious person ... not only are women more religious than men, but these prototypes make it easier for women to be religious than it is for men. (p. 223) Additionally, surveys conducted by The Barna Group (2004) have found that females are more likely than males to attend church on Sunday, 47% and 39%, respectively; females pray more often than do males, with 89% of females versus 77% of males reporting that they have prayed in the past week; females are 62% of the "born again" population; and 78% of females compared to 66% of males say that their faith is very important to them. LIMITATIONS OF THE STUDY Limitations of the study were related to instrumentation, procedures, the convenience sample, and the culturally limited sample. The study used unvalidated instruments because no validated instruments existed to measure client expectations or therapist beliefs about prayer in counseling. Further, because of the time involved for first-visit clients to complete intake information, the survey was necessarily brief. Future research could validated the measures and compensate first-visit clients to increase motivation to complete the surveys. Use of a localized convenience sample, rather than a randomized national sample, also lessens confidence that results can be generalized to all Christian therapists and clients. Survey completion rates (estimated at 52%) also leave unanswered questions as to the differences between those who completed the surveys and those who did not. Future research may need to compensate clients and offer greater compensation to therapists and office staff in order to increase completion ratios. Finally, despite substantial efforts at recruiting counselors and clients of color, the sample did not adequately represent the existing range of ethnic or religious groups in the United States. Therefore, conclusions that were reached in comparing religious groups should be considered tentative and should not be applied to non-White populations. Future research should certainly find more adequate ways to recruit counselors and clients of color. Future research might also explore a number of areas of interest that were raised during the research. For instance, how do various demographics relate to client preferences? How might one explain the lesser interest in prayer in counseling by younger clients or men? What are the most effective means for training mental health providers to adequately assess clients spiritually or to integrate spiritual interventions into the counseling process? How does one best stay aware of and avoid ethical violations when integrating spiritual interventions? CONCLUSIONS Ethical mandates, client expectations, and counselor beliefs all seem to point to the need to incorporate spirituality into counseling practice. This study therefore explored Christian therapists' and their clients' expectations about how best to do so with respect to prayer-related interventions. Although further research is certainly needed to confirm the results, the findings of this study seem to indicate strong expectations in this population for including several types of prayer in counseling. Eighty two percent of clients desired audible prayer as part of counseling. All of the therapists reported including prayer with and for clients as part of counseling. As would be expected, religiously conservative clients, clients who had previously experienced Christian counseling, and clients who were more prayerful in their personal lives had higher expectations of including audible and other types of prayer in counseling. As might be predicted by the multicultural literature which indicates that those who have the power (ie, therapists) should be the ones to acknowledge and invite the expression of diversity in counseling sessions (Sue & Sue, (1999), clients and therapists seem to believe that counselors should bring up the subject of prayer. Yet caution in including prayer in counseling is also warranted. An ethical quagmire looms as a very real possibility. For instance, Worthington et al. (1988) state that the general public envisions Christian counseling on a continuum from proselytization to "thoroughly secular counseling with no mention of religion" (p. 283). Our clinical experience confirms that some clients are reluctant to counsel with Christian therapists while other clients fear the exclusion of biblical principles, fearing that only secular psychology principles will be included. The current research results point to the need for sensitivity around spiritual issues and for spiritual assessment to help to determine client expectations. For instance, more liberal, male, Catholic, and younger clients may not want prayer to be included in counseling. Further, Christian therapists may need to be cautious about how frequently they include prayer given that they seem to be more inclined than their clients to do so. The literature also cautions providers to remain aware that including prayer in counseling carries ethical risks in the areas of client welfare (Genia, 2000; Sperry, 2001; Taylor, 2002; Weld & Eriksen, 2007; Worthington et al., 1996), multicultural sensitivity (Genia, 2000; Kennedy & Charles, 2001; Richards & Potts, 1995; Weld & Eriksen, 2007; Yarhouse, 1999), values, and countertransference (Agass, 2002; Astor, 2000; Case, 1997; Genia, 2000; Richards & Bergin, 1997; Weld & Eriksen, 2007; Yarhouse, 1999). These risks point to the need for spiritual assessment (Griffith & Griggs, 2001; Pargament, 2002; Richards & Potts, 1995) and adequate training in integrating spirituality (Magaletta & Brawer, 1998). 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Religious and spiritual interventions in therapy: An effectiveness study of Christian counseling. Unpublished manuscript, Iowa State University and Virginia Commonwealth University. Weld, D. C., & Eriksen, K. (2007). The ethics of prayer in counseling. Counseling and Values, 51, 125-138. West, WS. (2004). Spiritual issues in therapy--Relating experience to practice. Basingstoke: Palgrave Macmillan. Wolf, C. T., & Stevens, P. (2001). Integrating religion and spirituality in marriage and family counseling. Counseling and Values, 46(1), 66-75. Worthington, E. L., Jr. (1989). Religious faith across the life span: Implications for counseling and research. The Counseling Psychologist, 17, 555-613. Worthington, E. L., Jr., Dupont, P. D., Berry, J. T., & Duncan, L. A. (1988). Christian therapists' and clients' perceptions of religious psychotherapy in private and agency settings. Journal of Psychology and Theology, 16, 282-293. Worthington, E. L., Jr., & Gascoyne, S. R. (1985). Preferences of Christians and non-Christians for five Christian counselors' treatment plans: A partial replication and extension. Journal of Psychology and Theology, 13(1), 29-31. Worthington, E. L., Jr., Kurusu, T. A., McCullough, M. E., & Sandage, S. J. (1996). Empirical research on religion and psychotherapeutic processes and outcomes: A 10-year review and research prospectus [Electronic version]. Psychological Bulletin, 119, 448-487. Yarhouse, M. A. (1999). When psychologists work with religious clients: Applications of the general principles of ethical conduct. Professional Psychology: Research and Practice, 30, 557-562. Retrieved January 10, 2005, from Academic Search Premier database. Yoon, S.L. & Black, S. (2006). Comprehensive, integrative management of pain for patients with sickle-cell disease. Journal of Alternative & Complementary Medicine, 12, 995-1001. Retrieved January 26, 2007 from Academic Search Premier database. AUTHORS WELD, CHET. Address: Casas Church, 10801 N. La Cholla Blvd., Tucson, AZ, 85742. Title: Director of Pastoral Counseling. Degrees: Ed.D., Argosy University; M.Ed., University of Arizona; B.A., Ohio Wesleyan University. Specializations: marriage and family, depression and anxiety, integration of psychology and spirituality. ERIKSEN, KAREN. Address: Counselor Education Department, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33431; keriksen@fau.edu. Degrees: Ph.D., George Mason University; M.A. California State University, Fullerton. Specializations: counselor preparation, human development, diagnosis and treatment planning. CHET WELD, ED.D Casas Church, Tucson, Arizona KAREN ERIKSEN, PH.D Florida Atlantic University Correspondence concerning this article may be sent to Karen Eriksen, Ph.D., Counselor Education Department, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33431. keriksen@fau.edu
TABLE 1 Means, SDs, and 95% Confidence Intervals for Client and
Therapist Responses to the Prayer Survey Items
Client
Survey Item Therapist N M SD 95% CI
Prayerfulness Index (sum of Client 163 15.4 3.89 14.8, 16.0
next three items) Therapist 32 18.6 1.59 18.3, 19.4
1. Prayer is included in Client 164 5.3 1.67 5.1, 5.6
private life Therapist 32 6.7 0.51 6.6, 6.9
2. Client/counselor prays with Client 165 3.9 1.72 3.7, 4.2
other people Therapist 32 5.4 1.23 4.9, 5.8
3. Client/counselor agrees with Client 164 6.1 1.44 5.9, 6.3
the definition of prayer Therapist 32 6.7 0.51 6.6, 6.9
4. Counselor should bring up Client 162 4.9 1.80 4.6, 5.2
prayer Therapist 32 5.1 1.37 4.6, 5.6
5. Client should bring up Client 163 3.8 1.81 3.6, 4.1
prayer Therapist 31 4.2 1.00 3.8, 4.5
6. Counselor should pray Client 161 6.0 1.51 5.8, 6.2
outside of session Therapist 32 5.5 1.14 5.1, 5.9
7. Counselor should pray Client 159 5.0 2.05 4.6, 5.3
silently in-session Therapist 32 5.4 1.04 5.1, 5.8
8. Counselor should assign Client 163 4.3 2.11 4.0, 4.7
prayer homework Therapist 31 4.0 1.34 3.5, 4.5
9. Client desires/therapist Client 162 4.9 2.19 4.6, 5.3
uses audible prayer in- Therapist 32 5.5 1.3 5.0, 5.9
session
10. Counselor should pray Client 118* 5.7 1.33 5.4, 5.9
audibly
11. Client should pray audibly Client 117* 3.6 1.75 3.3, 3.9
12. Client and counselor should Client 118* 3.8 1.94 3.5, 4.2
take turns praying audibly
13. Counselor should stop at Client 134* 5.2 1.86 4.9, 5.5
any time to pray audibly
Mean Values Are Based on the Following Likert Scale Values:
1 = Never, 2 = Almost Never, 3 = Sometimes but Infrequently, 4 =
Occasionally, 5 = Often, 6 = Almost All the Time, 7 = Always
*Responses are from participants who answered higher than "2" to item 9.
TABLE 2 One-way Analysis of Variance of Client Prayer Intervention
Preferences by Religious Preference
Protestant Catholic Nondenom*
n M n M n M
Survey Item SD SD SD
Prayerfulness Index (total of next 46 16.0 13 13.4 72 16.6
three items) 3.4 4.0 3.1
1. Prayer is included in private 46 5.4 13 4.9 72 5.8
life 1.5 1.9 1.4
2. Client prays with other people 47 4.0 13 3.1 72 4.4
1.8 1.3 1.6
3. Client agrees with the 47 6.5 13 5.4 72 6.4
definition of prayer 1.0 1.7 1.1
4. Counselor should bring up prayer 46 4.8 12 4.1 71 5.6
1.7 2.1 1.4
5. Client should bring up prayer 47 3.6 13 3.1 71 4.3
1.7 2.3 1.7
6. Counselor should pray outside of 47 6.1 11 4.5 71 6.6
session 1.2 2.4 0.8
7. Counselor should pray silently 45 4.7 13 4.1 71 5.6
in-session 2.2 2.5 1.7
8. Counselor should assign prayer 47 4.4 12 2.4 72 4.8
homework 2.1 2.0 1.8
9. Client desires audible in- 47 5.1 12 3.5 71 5.7
session prayer 2.1 2.3 1.8
10. Counselor should pray audibly 36 5.8 7 4.7 58 5.8
1.2 1.9 1.3
11. Client should pray audibly 36 3.9 7 2.9 57 3.6
1.7 1.3 1.8
12. Client and counselor should 36 4.2 7 2.8 58 3.8
take turns praying audibly 1.9 1.5 2.0
13. Counselor should stop at any 46 4.7 13 2.3 67 5.3
time to pray audibly 2.2 1.6 1.9
Baptist
n M
Survey Item SD F p
Prayerfulness Index (total of next 12 14.9
three items) 3.3 3.74 <0.022
1. Prayer is included in private 12 4.7
life 1.6 2.95 <0.04**
2. Client prays with other people 12 3.7
1.8 2.70 <0.052
3. Client agrees with the 12 6.6
definition of prayer 0.9 3.43 <0.021 & 2
4. Counselor should bring up prayer 12 4.7
1.5 5.13 <0.012 & 3
5. Client should bring up prayer 12 3.9 0.08
1.7 2.28
6. Counselor should pray outside of 12 5.7
session 1.2 10.49 <0.00011 & 2
7. Counselor should pray silently 12 5.2 3.05 <0.04***
in-session 1.3
8. Counselor should assign prayer 12 5.3
homework 1.8 6.04 <0.0011, 2 & 4
9. Client desires audible in- 12 5.2
session prayer 1.7 4.54 <0.012
10. Counselor should pray audibly 10 6.1 0.14
1.2 1.84
11. Client should pray audibly 10 3.5 0.58
2.2 0.65
12. Client and counselor should 10 3.8 0.37
take turns praying audibly 2.3 1.05
13. Counselor should stop at any 12 5.5
time to pray audibly 1.8 4.39 <0.00011, 2 & 4
*"Non-denom" = Nondenominational/Evangelical
Mean Values Are Based on the Following Likert Scale Values:
1 = Never, 2 = Almost Never, 3 = Sometimes but Infrequently, 4 =
Occasionally, 5 = Often, 6 = Almost All the Time, 7 = Always
Note: 94.5% of participants responded to the item that categorizes
religious preference (N = 156); 84.8% of the 165 responded in ways that
can be coded according to the above four religious preferences (N =
140). Also, Bonferroni-corrected post hoc t-tests indicate significant
differences between the following groups:
1 Catholic vs. Protestant (Catholics scored lower)
2 Catholic vs. Nondenominational (Catholics scored lower)
3 Protestant vs. Nondenominational (Protestants scored lower)
4 Catholic vs. Baptist (Catholics scored lower)
**None of the Bonferroni-corrected post hoc t-tests showed statistically
significant differences, but the most striking difference was between
Baptist and non-denominational groups with a mean difference of -1.15
and p < 0.10. It appears that the Bonferroni correction was too
conservative in this case.
***None of the Bonferroni-corrected post hoc t-tests showed
statistically significant differences, but the most striking difference
was between nondenominational and Catholic groups with a mean difference
of 1.44 and p < 0.09. It appears that the Bonferroni correction was too
conservative in this case.
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