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Literature Review

Spirituality may affect a couple’s dynamics, and it might also influence couple therapy. However, spirituality often is not brought up in couple therapy, even with clients who want to talk about it. As some couples might consider spiritual topics as off-limits with secular providers, they might not bring up their religious concerns.

Three Types of Spiritually Integrated Couple Therapies

However, spiritually integrated couple therapies (SICTs) exist. Two examples are Hope-Focused Couple Therapy (HFCT) and PREP. Research on both began as the study of secular couple enrichment/prevention treatments (Markman et al., 1994; Worthington et al., 2015). They have been practiced as Christian-oriented treatments prior to the research on secular treatment (Markman et al., 2004; Ripley & Worthington, 2014; Stanley et al., 2001, 2014; Worthington, 2005). Both incorporated methods from secular therapies but published integrated treatments (of different secular methods and different Christian approaches), making their conduct explicit and replicable (Stanley et al., 2014; Worthington, 2005). PREP largely relied on classical (Jacobson & Margolin, 1979) and integrative behavior couple therapy (Jacobson & Christensen, 1996).

HFCT relied on a more eclectic mix including classical behavior couple therapy (Jacobson & Margolin, 1979), integrative behavior couple therapy (Christensen et al., 2023), cognitive-behavioral couple therapy (Baucom et al., 2023), emotionally focused couple therapy (Johnson et al., 2023), attachment theory (Bowlby, 1988), structural family therapy (Minuchin, 1974), strategic problem-solving therapy (Haley, 1976), and solution-focused couple therapy (Franklin et al., 2023). Later, it incorporated methods from ACT (Acceptance and Commitment Therapy, Lawrence et al., 2023) and forgiveness and reconciliation (Worthington, 2003). Similar to numerous studies of couple psychoeducation that have been found to be effective, HFCT has been found to be effective (Ripley et al., 2014), and follow-up studies using couple-therapy clients who completed therapy two to ten years previously have shown effects to generally last (Ripley, Solfelt, et al., 2022). For such evidence-based treatments, meta-analyses have investigated whether they are as effective as the secular treatments that often compose the majority of the approach. The most up-to-date and extensive meta-analysis found that matched spiritually accommodated treatments relative to unaccommodated treatment had equal or better psychological outcomes and greater spiritual well-being (Captari et al., 2018).

Other couple therapies were primarily secular couple therapies, later modified to include Christian principles. For example, emotionally focused couple therapy (EFCT; Greenberg & Meneses, 2020) was spiritually adapted (Nurlu, 2020) and for Christians (May, 2025).

A third group of spiritually accommodated couple therapies is difficult to identify, though it is widely practiced. Those approaches typically are unpublished. Practitioners often have an eclectic secular approach, integrating Christian principles and methods from either practical theology or explicitly Christian approaches into it. Alternatively, they have a more explicitly Christian (or other religiously informed) approach based on practical theology or other explicitly Christian approaches, and they integrate secular methods within it. In both cases, no explicit rendition of their approach is available. In fact, it might be differently constructed for patients with different beliefs, values, and psychological needs.

Characteristics of the Three Types of SICT

These constitute three types of SICT. The first category is evidence-based. There are studies that support a particular approach with the Christian integration made explicit. Thus, it will be referred to as evidence-based Christian couple therapy.

The second category might be based on evidence-based Christian couple therapy, but the entire approach has not been used. Rather, parts have been abstracted. Some of what was selected might be effective, but other parts might not. Also, the approach might have included methods from centuries of practical theology (e.g., praying to God for guidance, searching Scriptures). Clinicians might practice their secular theoretical approach (presumably supported by research evidence) and yet confidently use religiously referring interventions (e.g., prayer, May et al., 2019; forgiveness, Anderson & Natrajan-Tyagi, 2016; Wade et al., 2014) with some assurance that that intervention—at least—likely produces positive effects. However, with this approach, what is or is not effective for counseling and therapy has not been scientifically investigated. No clinically scientific evidence has been adduced that supports exactly how well the approach works. This will be referred to as Christian couple therapy based on uncertain evidence. We note that while the effectiveness of the evidence is uncertain, it is not necessarily ineffective. Nor is it necessarily effective. Its effectiveness is “uncertain.”

The third category has evidence only from a practitioner’s use (typically) in a local practice. Local practitioners might have compelling evidence that their approaches work as they apply it to their particular clientele. This might be adequate for convincing a local license board or local clients. However, because it has not been investigated with scientific controls, it has no claim to general evidence-based treatment. That awaits clinical psychological investigation. It will be referred to as Christian couple therapy with local evidence.

Determining Integration by Examining Individual Methods

Another way of seeking to employ evidence-based practices is not concerned with an entire approach to therapy but with drawing upon methods that are evidence-based. They have been investigated scientifically as a method. These might be relatively brief, such as one line of research that found that couples often use the common spiritual practice of praying with or for one’s partner. Prescribing prayer by one partner for the other has been investigated and found to be effective (Fincham & Beach, 2014). Another more complicated method is empty chair dialogues (see Greenberg & Meneses, 2020), which have been investigated as a method in secular therapy, commonly emotion-focused couple therapy (Greenberg & Meneses, 2020). A still more complicated method, but not rising to the level of a therapeutic approach, is REACH Forgiveness (Worthington, 2003). This has been investigated in numerous studies (for reviews, see Worthington, 2024a, 2024b). Whereas some methods are helpful in psychotherapy, others are harmful. Mahoney (2013) suggested that some religious actions—such as trying to triangulate God siding with one partner against the other partner —can weaken relational bonds.

Often highly religiously committed couples may request that spiritual or religious concerns be used in their couple therapy (Ripley & Worthington, 2014). Or they might prefer pastoral counseling or care for marital concerns (Mutter et al., 2010). Couples might believe that religiously and spiritually consistent counseling may be received from clergy whom they know and trust, or from clergy who have a local reputation for helping couples effectively.

Research on SICT: Self-Reports by Couple Therapists

Religiously accommodated interventions in couple therapy have been investigated for their use and effectiveness in empirical studies. Hook and Worthington (2009) surveyed 630 American Association of Christian Counselors (AACC) about their counseling practices. Counselors were categorized as lay, pastoral, or professional counselors (mostly master’s-level counselors). All counselors reported openness to dealing with spirituality in counseling. Professional counselors reported seeing the most couples each year (n = 22; about 14 of which were Christian, defined as both partners being Christian), relative to pastoral counselors (n = 16; about 12 of which were Christian) or lay counselors (n = 6; about 5 of which were Christian). Regardless of category, respondents reported that religion is brought up in counseling with approximately 82% of their couple cases. Its salience, however, was higher in pastoral counseling (89%) than either professional counseling (80%) or lay counseling (72%). Almost all (98.4%) reported using explicit religious practices in couple counseling. Viewing religious techniques as appropriate for use in counseling was predicted by the counselor’s higher religious commitment and higher number of cases in which religion had been dealt with in counseling.

Respondents reported which approaches to secular couple counseling they preferred and drew methods from. Professionals preferred all secular approaches—systems, cognitive-behavioral, behavioral and integrative behavioral, solution-focused, EFT, and insight-oriented (in that order of average preference—to both pastoral and lay counselors). They also reported the Christian approach to couple counseling or couple education they preferred. Parrott and Parrott’s (1996) relationship approach (Parrott & Parrott, 1996) to couple psychoeducation was most preferred. HFCT and PREP (both used in therapy and psychoeducation) were rated virtually equal in AACC members’ preferences.

Christian couple counselors who responded to the survey were highly religious, and their personal religiosity affected their attitude toward incorporating religion in counseling. However, this study revealed little about how HFCT (or any approach) was used in actual therapy. Preferences for an approach did not imply how much or whether an approach was used . Nor did it imply whether counselors strictly followed the method or drew methods from the approaches. A different methodology—surveying treatment as usual (TAU) session by session—was needed to begin to answer some of those questions.

Research on SICT: Treatment-as-Usual (TAU) Studies

Two extant studies have examined SICT as it is usually practiced (i.e., TAU; Hook et al., 2014; Ripley, Worthington et al., 2022). The methodology needed involves both querying counselors on what they perceived happening in couple counseling with specific couples, who also report on what they perceive was done in each session.

Hook et al. (2014) studied 68 Christian couples (73% Caucasian, 17% African-American, 5% Latino, 2% Asian; 89% married; 23% previously divorced) treated by 44 Christian couple therapists in SICT for up to eight sessions examined relationship satisfaction and working alliance. They found that about 60% of couples discussed religion generally, and about half prayed with their therapist within the first eight sessions.

Five religious tasks (i.e., discussion of religious faith, prayer in session, assignment of religious tasks, directions to consult scripture, and forgiveness by God) were assessed session by session. All five were used in about half of the sessions. The religious commitment of clients was positively related to the number of religious techniques used. Hook et al. did not analyze the effectiveness of the specific religious techniques. Nor did Hook et al. assess the use of methods from established evidence-based therapies. Overall, clients improved over time in dyadic adjustment and working alliance. Clients reported high satisfaction with couple therapy.

Ripley, Worthington et al. (2022) investigated several research questions about what is happening in SICT. (1) What baseline characteristics, attitudes, or symptoms predict engagement in SICT? Ripley, Worthington et al. found that early terminators had higher couple dissatisfaction initially, less efficacy, and more psychological distress. (2) What theories are used in SICT? Ripley, Worthington et al. found that few clinicians adopted a single theoretical approach. Rather, they drew from many approaches—usually employing evidence-based methods from several theories or spiritual evidence-based methods not affiliated with a particular theory (like prayer or forgiveness). Most SICTs were built—at least to some extent—on established evidence-based models, and clinicians often reported drawing from more than one theory. (3) What spiritual practices are used in SICT by couple therapists and couples? Therapists reported they used prayer and forgiveness in about a third of their end-of-session reports—usually in response to clients. Thus, clients, not therapists, seem to have mobilized explicit spirituality in sessions. Clinicians followed clients’ leads when using spiritual techniques and practices, which is in keeping with most ethical training on religion in treatment (Richards & Potts, 1995). Overall, couples’ use of spiritual practices was moderate. There were low rates of explicit religious practices in sessions and only about half of couples engaged in prayer for their partner or relationship between sessions.

Findings in these studies of couple therapy were similar to some findings in prior studies of individual psychotherapy that examined the use of religious techniques (e.g., Wade et al., 2007; Walker et al., 2004, 2011). In a meta-analysis of individual therapy by Walker et al. (2004), religious therapists reported that, at least once in a case, they dealt with forgiveness in 42% of all their cases, referred to scripture in 39%, confronted sin in 33%, and used prayer in 29%. Hook et al. (2014) observed that religious therapists doing couple therapy reported using specific religious techniques in about a third to half of individual sessions. Couples research on couples and their therapists (Hook et al., 2014; Ripley et al., 2022) has thus far demonstrated this same trend—clients seem to want spiritual engagement in seeking a religious therapist. Ripley, Worthington et al. (2022) also reported on improvement in SICT over time. They found a positive trend towards improvement, but many relational measures were not significant at six sessions. Direct measures of relationship satisfaction, emotional forgiveness, and relationship efficacy did not increase with time. Ripley, Worthington et al. did not report session-by-session use of methods from evidence-based treatments—either from therapists’ or clients’ perspectives.

The Present Study

Ripley, Worthington et al. (2022) collected session-by-session data. In the present study, we used data (previously unreported) from Ripley, Worthington et al.’s (2022) study of couple therapists who identify as using SICTs in TAUs. We zeroed in on Hope-focused Couple Therapy (Ripley & Worthington, 2014; Worthington, 2005). Necessarily, though, we report on other theoretical approaches, either whole-cloth or by extracting specific methods from them.

HFCT is eclectic relative to secular theories of couple therapies—integrating structural, strategic, emotion-focused, integrative behavior therapy, and psychodynamic theorizing. It uses an overarching conceptual scheme promoting hope, a strategy of promoting love, work, and faith, and techniques that integrate both talk and environmental change. It is also flexible enough to allow most methods of standard couple therapies within its framework. HFCT integrates virtues, permits the use of numerous Christian theologies, and is supported by empirical evidence on the overall approach and its components. Its flexibility allows it to be widely used in SICT (Hook Worthington, 2009) and non-SICT (Worthington & Ripley, 2024). It is supported by research documenting positive relational outcomes in university clinic settings with both Christian and secular clients (Jakubowski et al., 2004; Ripley et al., 2014; Worthington, 2005).

Emotion-focused couple therapy (EFCT) is also frequently used in couple therapy (Greenberg & Meneses, 2020). EFCT is an empirically supported treatment for which spiritual integration resources have been created (Hawkins et al., 2019). Spiritually integrated versions of EFCT lack direct research on outcomes but are supported by case studies (Nurlu, 2020).

We attempted to answer two main research questions. Which therapeutic orientation is the most popularly used across all sessions? Which therapeutic orientation is the most popular approach across sessions with all couple clients? This often entails using methods associated with the theoretical approach to therapy but not using the therapy throughout whole sessions or whole treatment protocols with particular couples. We hypothesize that HFCT will be identified as the most-preferred whole therapy, and methods from it will be the most-used when examining session-by-session.

SICT, as practiced by most practitioners in this study (see Ripley, Worthington et al., 2022), (1) was tailored to the spirituality of the couple, rather than the therapist, (2) was focused largely on emotional experiences in treatment, (3) most frequently includes spiritual practices of prayer for couples, discussion of hope and forgiveness, and encouragement to listen to one’s heart, and (4) was typically theoretically eclectic. However, Ripley, Worthington et al. found that most TAUs were influenced primarily by evidence-based theories such as hope-focused (Ripley et al., 2014) or emotion-focused SICT (Hawkins et al., 2019).

The outcomes of these studies relate to psychological and sometimes spiritual well-being. Most published research to date (cf. Hook et al., 2014) did not attend to the following: what the counselors did (if anything) apart from the manual, treatment processes, reactions of the clients to what counselors did, or spiritual practices of the clients outside of therapy.

Method

Therapists and Clients

Participants were recruited from five large explicitly Christian counseling practices and numerous solo practices that advertised conducting SICT in the Mid-Atlantic region. A total of 29 therapists (19 female, 10 male; ages ranged from 25 to 75 years old) participated. Most identified as Caucasian (75.9%), followed by African American (13.8%), Asian American (3.4%), and Latino (3.4%). Of the 29 therapists, 18 were licensed clinicians (15 counselors, 2 psychologists, and 1 social worker). The remaining 11 were unlicensed and engaged in practicum, internship, or residency training. Their years of practice ranged from 1 to 36 years (M = 11.4, SD = 10.7). Therapists reported drawing from various theoretical frameworks in their work with couples. All self-identified as Christian. Additionally, most engaged in individual spiritual disciplines, including daily prayer (91%) and scripture reading (55%).

The final sample of clients consisted of 68 couples. Among these couples, 81% were married, 11% engaged, and 8% in exclusive relationships. Clients had a mean age of 40.6 years (range: 20–65). The majority of participants identified as Caucasian (69%), African American (14%), with fewer identified as Latino (7%), Multiracial (6%), Asian (3%), American Indian (1%), Polynesian (1%), and Other (1%). Nearly all clients (96%) identified as Christian, with 1% identifying as Muslim, 1% as Spiritual, and 2% as Unsure. The vast majority (94%) considered religion/spirituality (R/S) an important part of their lives, and 90% preferred discussing R/S issues in counseling when relevant. Of the clients, 33% indicated that R/S issues had contributed to some of their relational challenges.

Therapy Session Measures

CAMOS Therapist Session Checklist (TSC; Sanders et al., 2017). This is one component of the CAMOS system, which was administered each session. The TSC allows therapists to quickly record client issues/topics addressed, therapeutic approaches and interventions used, and spiritual interventions used or encouraged in each session.

Six-session counseling-summary checklist. At the sixth session or involvement in the research, clinicians completed a checklist to record the couple’s presenting problem, and spiritual issues addressed throughout treatment. They identified their use of relationship-specific approaches to treatment, any supplementary resources (book/religious activities), and their own approach to involving spirituality into treatment with the couple.

Procedure

The study was approved by the Institutional Review Board with Advarra Inc., in compliance with all ethical regulations for this type of research. Specific informed consent was used, and client data were coded for disguise. To recruit participants, we invited five large counseling practices in Coastal Virginia and the Research Triangle of North Carolina that publicly advertise providing spiritually integrated couple therapy (SICT, see Worthington et al., 2023). At each site, we identified leaders who recruited additional clinicians within their respective practices. This yielded the registration of 23 clinicians.

To further increase clinician participation, we employed social media outreach, personal contacts, and snowball sampling—generally within the Mid-Atlantic region—to identify solo clinicians who advertised providing SICT (including Christian couple counseling or therapy) in the Mid-Atlantic identified an additional 33 interested clinicians. Of the 56, co-therapy was used in 12 cases. However, only one randomly selected clinician from each co-therapy case provided therapist ratings; thus 12 clinicians were willing to participate but were not registered.

Thus, 56 clinicians registered for participation. Of those, 24 subsequently withdrew or provided no couples meeting inclusion criteria to the database. Of those 32 who began data collection, three did not provide sufficient data for inclusion. Therefore, 29 clinicians provided data that were analyzed. All clinicians received a video training covering the ethics of SICT and online data collection procedures. Given the study’s therapy-as-usual (TAU) design, no standardized treatment protocol was provided.

Clients were invited to participate by their therapists and were required to confirm that they were seeking a spiritually integrated couple therapy and were willing to complete weekly surveys for the first six sessions of couple therapy. Thus, the study targeted a specific subsample of couples. The research protocol required both therapists and couples to complete baseline surveys and weekly session surveys for at least the first six sessions, though many cases continued participation voluntarily beyond this period.

Data were collected online from both therapists and partners, with hard copies of instruments available upon request. As an incentive, therapists received a $5 stipend per session for managing and delivering data. Additionally, to support treatment monitoring, therapists were provided with their clients’ ratings on relevant measures every two weeks. A previous study using these therapists and couples has focused on clients’ outcomes (Ripley, Worthington et al., 2022). The present study focuses on therapists’ approaches. Clients’ data are included for a complete description of the study.

Results

These 29 therapists and their 68 clients collectively contributed data on 278 sessions. Some therapists have provided services to more than one couple: 10 therapists counseled one couple, 11 therapists counseled two couples, and four therapists counseled nine couples.

Only the first six sessions were relevant to the present study, though many couples continued therapy after the first six sessions. Within the initial six sessions, couples saw their therapists a different number of sessions. Eight couples completed only one session of therapy, 13 couples completed two sessions, six couples completed three sessions, five couples completed four sessions, ten couples completed five sessions, and 26 couples completed six sessions. A few couples who completed all six sessions submitted data for fewer than the six.

Unlicensed and Licensed Clinicians’ Therapist-Reported Use of Therapies within Sessions

Therapists were queried as to whether they used methods or techniques from particular orientations within each session. It is possible for therapists to use methods drawn from many approaches within a single therapy session; thus, in Table 1, the number of sessions in which therapists reported using methods from different (n = 406) exceeds the actual number of sessions (n = 278). Across actual 278 sessions, hope-focused therapy methods were reported to have been used in 109 of those sessions, accounting for 39.2% of the sessions. Emotion-focused therapy methods were reported to have been used in 80 of the sessions (28.8% of the sessions). Methods from spiritually integrated therapies (general spiritual and specifically Christian) and from general couple therapies were also used, ranging from 15.5% to 22.3% (see Table 1). The behavioral therapies were less frequently used, in less than 10% of sessions (see Table 1). Table 1 summarizes the number of sessions each therapy was reported to have been used, and the proportion out of 278 sessions.

We observed some disparities between unlicensed and licensed therapists. Unlicensed therapists, who were individuals still in training, were more likely to use hope-focused therapy than licensed therapists (72.5% versus 17.8%, for unlicensed versus licensed therapists, respectively). Relative to unlicensed therapists, licensed therapists tended to use more emotion-focused therapy methods (19.3% versus 34.9%, for unlicensed versus licensed therapists, respectively). For spiritually integrated approaches—general spiritual methods (19.3% versus 24.3%, for unlicensed versus licensed, respectively) and general Christian methods (9.2% versus 19.5%, for unlicensed versus licensed, respectively). General spiritual methods included things like discussing hope, compassion, or self-control. General Christian methods included things like silently praying for the couple, discussing forgiveness, encouraging partners to listen to their hearts, and encouraging partners to pray for each other and themselves. Methods of general couple therapy included things like assessment, communication and conflict training, intimacy management, dealing with infidelity and trust issues, and discussions of termination. Unlicensed therapists used slightly less of these than did licensed therapists (15.6% versus 19.5%, respectively). Therapists also reported using specific methods identified with different types of behavioral therapies (e.g., Gottman method couple therapy, integrative behavior therapy, cognitive-behavior couple therapy, and ACT). Lebow and Snyder (2023), in the Clinical Handbook of Couple Therapy, 6th ed., classify Gottman’s method couple therapy as integrative rather than behavioral. None of these was reported to have been used in more than 10% of the sessions. The last two columns of Table 1 summarize these results for each group individually.

Table 1. Frequency and percent of sessions in which methods drawn from different types of therapy were used by unlicensed and licensed therapists

Proportion of Couples for Which Each Type of Therapy was Used

In Table 1, we reported the number of sessions that methods from each type of therapy were used. It might be possible for a therapist to scatter the use of methods from a particular approach, say HFCT, across all clients—perhaps using one or two favorite methods with most couples. Or it might be that a therapist decided that some clients were appropriate for, say HFCT, and the therapist used it for every session but did not use it at all for other couples. Different clients may benefit from different therapeutic orientations at different times, and some might be especially suited for a uniform approach. Some therapists might be particularly devoted to a particular therapeutic approach due to receiving training in only one or two approaches or simply strongly preferring the approach to all others. Other therapists might not be devoted to any particular approach but choose therapeutic methods from a variety of approaches.

To determine whether therapists used their methods more within clients or scattered them across clients, we consider therapists’ reports of how many of their couple-clients they used each particular approach. Therapists reported which approaches were used with each particular couple. However, care is needed in interpreting therapists’ reports. If HFCT was used with 40% of the clients, this does not inform us whether it was used in every session or briefly in one session. It tells us more about which client-couples it was not used with—that the therapist decided not to use it with 60% of the couples. In the first two columns of Table 2, we report the data at client-couple level.

Across the 68 clients, HFCT was reportedly used with n = 27 of the 68 couples, accounting for 39.7% of all couples (see Table 2). Emotion-focused therapy (n = 33, 48.5%). It was thus employed more often than was the HFCT. From these data, though, we cannot tell whether it was used exclusively with how many couples or (at the other end of the spectrum) a particular method was used once with each couple.

General spiritually integrated therapy (n = 28, 41.2%), general Christian therapy (n = 23; 33.8%), and general couple therapy (n = 26; 38.2%) were virtually indistinguishable in use to HFCT (not used with 59.3% of the couples). From these data it is impossible to determine whether these overlapped (i.e., about 60% to 70% of the couples were not open to spiritual or specifically Christian methods) or whether they represented different couples (i.e., some couples might have been open to spiritual methods but not to specifically Christian methods, or vice versa). Among behavioral therapies, which were generally used in approximately 10% of the sessions, Gottman method couple therapy was the most popular.

Table 2. Distribution of therapy orientations using methods drawn across 68 couple clients.

Utilization Rate with Couples for Whom Methods from a Theoretical Approach Was Used

To determine how much of therapy was dominated by the use of methods from each approach, we examined the proportion of sessions for each client that used a specific therapy orientation. For instance, if a couple came for six sessions, and if HFCT methods were used in 2 of them, that would be a 33.3% utilization rate. If Gottman method couple therapy methods were used in 4, that would be a 66.7% utilization rate.

The last column of Table 2 summarizes the utilization rate. We see that, across all the couple-sessions, HFCT had an overall 33.5% utilization rate. For each client for which HFCT was used, it was used in one-third of the sessions. This was followed by emotion-focused therapy (29.6% utilization rate), general spiritually integrated therapy (26.3% utilization rate), and others. The utilization rate for behavioral therapies was generally not high. Gottman method couple therapy was clearly more often utilized than other variations of behavioral approaches.

Discussion

By studying practicing couple therapists and couples doing treatment as usual (TAU) over the course of at least the first stage of ongoing treatment, we studied what might actually be going on in the early phase of couple therapy that had been advertised as spiritually integrated. Virtually all were Christian-oriented. This attempt at practice-informed research using the TAU method diverges from research in which clinical scientists create manualized interventions and apply them to clients or to people who have subclinical levels of disturbance. For those studies, the randomized controlled trial is the gold standard. However, at least from our data, few therapists in actual clinical practice select a method that is compatible with their clients and that they are trained to conduct and prefer to conduct. They then carry treatment out throughout couple therapy—at least throughout the first six sessions, which we assessed. TAU research shows a strongly eclectic approach within our sample.

This study of couples and couple therapists applying their approaches in TAU is a unique contribution to the literature. of our investigation. It has the promise of revealing what is actually done in Christian couple therapy from both therapist and couple viewpoints. In the present research, we considered only the therapists’ viewpoints. This research has the potential to reveal (1) how many sessions (of the first six) therapists used each approach they drew from, (2) how frequently they did not use an approach in their repertoire, and (3) when they did use the approach, in what fraction of the sessions they used it.

Limitations

Our study has frank limitations. Instead of listing them last, we believe it is important to note them before we seek to interpret the findings to aid interpretation. What can be revealed in any research on couple therapy depends on how precisely researchers ask the questions and whether therapists and clients interpret questions as researchers intended. In the present research, some items were asked in ways that created some ambiguity in therapist responses.

Perhaps the main source of ambiguity was in differentiating the term “general spiritually integrated therapy” from “general Christian counseling.” The “general spiritually integrated therapy” term was mandated by the grant-funding overall project of which this present project was a part. Our particular concern, which was reflected in the therapists who responded to our request for participation, was Christian counseling. Clearly, those terms overlap, and the overlap might have resulted in confounded responses. For instance, some therapists likely interpreted Christian counseling as part of spiritually integrated treatments. However other therapists likely interpreted this as a way of differentiating Christian counseling from spiritually integrated treatments that might entail other religions or new-age spirituality. Thus, with this potential for confounding, we have chosen to report, but not to interpret findings of those two categories.

A second limitation also affects interpretation. Methods of HFCT were used with fewer clients than methods of EFT and general spiritually tailored approaches. Therapists likely had a problem identifying what methods “belong” to what therapies. EFT is a clear, recognizable approach. Some methods are highly identified with it. For example, interpreting attachment relationships and an empty-chair dialogue are two prime examples. The ambiguity arises because the HFCT approach includes both of those within its recognizable methods. The centerpiece of the HFCT is restoring damaged emotional bonds, and thus, a HFCT couple therapist is almost certain to speak of attachment relationships. In addition, a major aspect of the HFCT is promoting forgiveness, and empathy is key to both forgiveness and reconciliation (i.e., FREE; Forgiveness and Reconciliation through Experiencing Empathy). Thus, if a therapist employed either or both methods, it is uncertain to which approach the therapist would attribute its use.

A third limitation involved our sampling. We recruited primarily from the Mid-Atlantic region. We also focused on therapists’ use of HFCT. Therapists who participated in this study were not randomly selected. Regent University, the institution primarily funded to conduct the present research, was in the Mid-Atlantic region. Many program graduates began post-degree practice within the Mid-Atlantic region. Because training in the HFCA was prominent at Regent University over the ten years prior to the onset of this present study, the chances of having been trained in the HFCA within the Mid-Atlantic region were not representative of the world, the United States, or other regions of the United States. Thus, it is likely that reported use of HFCT is over-representative of what might be found in truly random sampling.

Another limitation on the generalization of our findings also arises due to sampling. This limitation is because only 29 couple therapists were in our sample (18 licensed, 11 unlicensed). Although the couple therapists supplied 68 couples who provided data (see Ripley, Worthington et al., 2022), 29 therapists is a small number on which to base strong generalizations. Thus, our conclusions are tentative, and we hope will be generative to other researchers who will follow up with larger and more randomly selected therapists.

A fifth limitation is due to the treatment of couples. We examined data from only the first six sessions. So, what we did discover, applies only to the beginning of couple therapy. This is nevertheless important, because many couples drop out of therapy within the first six sessions. In our sample, only 26 of the 68 couples (38.2%) finished all six sessions.

Despite these substantial limitations, this study addressed issues that had not been previously studied. Thus, questions were raised that should prove heuristic in future couple research on how therapists actually decide on the methods they employ in therapy with couples.

Interpretations of Findings

When examining all 278 sessions, HFCT methods were reported to have been used in 109 of those sessions, and EFCT methods in 80 of the sessions. However, unlicensed therapists, who were individuals still in training, were more likely to use HFCT than were the licensed therapists, and the difference was substantial—72.5% for unlicensed versus 17.8% for licensed therapists. On the other hand, unlicensed therapists tended to use fewer EFCT methods (19.3%) versus 34.9% for licensed therapists.

Several potential explanations might explain these differences. For one, trainees might not yet have been exposed to Christian-accommodated EFCT (May, 2025; Nurlu, 2020). Perhaps this reflects a number of trainees from Ripley’s HFCT-oriented clinic (Ripley, Solfelt et al., 2022). For another possible reason, training materials for HFCT are more explicit and easily discoverable through books and a public website (www.hopecouples.com) than for Christian-oriented EFCT. Another possible reason is that HFCT might be simpler for inexperienced trainees to master. For yet another possible reason, training in explicitly Christian EFCT has often occurred at AACC World conferences and (on alternate years) National conferences, and trainees are less likely to attend such events and thus less likely to have been exposed to Christian-oriented EFCT. Research is needed to parse the reasons for the rather stark differences between licensed and unlicensed providers.

Only about 40 percent of all therapists used any HFCT methods, so 60 percent never used HFCT methods. However, EFCT was used by almost 50 percent of all therapists. From these data, though, we cannot discern whether it was used exclusively with how many couples or (at the other end of the spectrum) a particular method was used once with each couple.

Thus, we examined utilization rates once a therapist reported using HFCT (and EFCT). Across all the couple-sessions, HFCT had an overall utilization rate of about one-third of the sessions. For EFCT, however, its utilization rate was about 30 percent of the sessions.

Utilization rate for behavioral therapies was generally not high. Whereas among general secular therapists, behavioral and cognitive-behavioral approaches are generally well subscribed to (Lebow & Snyder, 2022). Understanding why this does not seem to be the case among Christian therapists is worth further investigation.

Gottman method couple therapy (Gottman, J. M., & Gottman, J. S., 2023), which began as a behavioral couple therapy, but has become more eclectic and emotionally sensitive in recent years (see Lebow & Snyder, 2023), was more often used than other behavioral approaches. AACC conferences and special events have featured some training in Gottman method couple therapy, likely accounting for the highest utilization of that approach among all of the behavioral couple therapies. In addition, the Gottmans’ YouTube presence is strong—much stronger than other behavioral couple approaches. This is likely to provide more exposure for the approach, which is likely to translate into more use.

In conclusion, although this study has substantial limitations, it revealed unique findings relative to existing research on the process of Christian couple therapy. In addition, it also raised new questions for future investigation about how therapists in the TAU practice make decisions about which approaches to draw methods from as they seek to treat couples.

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