Iranian J Publ Health, Vol. 41, No.6, Jun 2012, pp.12-20 .docx

Iranian J Publ Health, Vol. 41, No.6, Jun 2012, pp.12-20
Review Article
Crisis Management of Tohoku; Japan Earthquake and Tsunami,
11 March 2011
*M Zaré 1, S Ghaychi Afrouz 2
1. International Institute of Earthquake Engineering and
Seismology (IIEES), Tehran, Iran
2. Mining Engineering, School of Mining Engineering,
University College of Engineering, University of Tehran,
Tehran, Iran
(Received 12 Dec 2011; accepted 22 Apr 2012)
Introduction
The magnitude 9.0 Japan’s Tohoku Earthquake
occurred at 14:46 local time on Friday, 11 March
2011, 125 km east coast of Honshu and 380 km
far from Tokyo and rattled the large parts of Ja-

pan and some part of east China and Russia with
30 km depth of the hypocenter (1). This earth-
quake that lasted approximately 3 minutes (170
seconds) caused a 130 km long by 159 km wide
rupture zone on the pacific plate subduction zone
and followed by a huge tsunami with more than
40 meter waves. The destructive aftermaths of this
incident made an irreparable disaster not only for
the Japan, but also for the whole world because
except for the enormous death toll and debris, the
damages of nuclear power plants were a hazard-
ous unexpected tragedy.
Casualties and damages
According to the report of the Japanese National
Police Agency, 15854 dead, 3167 missing and
26992 injured across twenty prefectures are the
result of this devastating earthquake and tsunami
which ruined more than 125000 buildings. Moreo-
ver, it caused long blackouts for more than 4.4
million buildings and left 1.5 million buildings out
of water for days (2), also large fires were triggered
one after another even for weeks after the main
quake. Explosion and demolition of the Fuku-
Abstract
The huge earthquake in 11 March 2012 which followed by a
destructive tsunami in Japan was largest recorded
earthquake in the history. Japan is pioneer in disaster
management, especially earthquakes. How this developed
country faced this disaster, which had significant worldwide
effects? The humanitarian behavior of the Japanese
people amazingly wondered the word’s media, meanwhile the
management of government and authorities
showed some deficiencies. The impact of the disaster is

followed up after the event and the different impacts are
tried to be analyzed in different sectors. The situation one year
after Japan 2011 earthquake and Tsunami is over-
viewed. The reason of Japanese plans failure was the scale of
tsunami, having higher waves than what was as-
sumed, especially in the design of the Nuclear Power Plant.
Japanese authorities considered economic benefits
more than safety and moral factors exacerbate the situation.
Major lessons to be learnt are 1) the effectiveness of
disaster management should be restudied in all hazardous
countries; 2) the importance of the high-Tech early-
warning systems in reducing risk; 3) Reconsidering of extreme
values expected/possible hazard and risk levels is
necessary; 4) Morality and might be taken as an important
factor in disaster management; 5) Sustainable devel-
opment should be taken as the basis for reconstruction after
disaster.
Keywords: Japan, Earthquake, Tsunami, Disaster, Crisis
Management, Fukushima
*Corresponding Author: E-mail address: [email protected]
mailto:[email protected]
Zaré & Ghaychi Afrouz.: Crisis Management of Tohoku …
13
shima I Nuclear Power Plant (Fukushima Daiichi),
which generated radioactive contamination near
the plant’s area with irreversible damages to the
environment, was one the most significant issues
of this catastrophe and ranked 7 (the most sever
level for nuclear power plant) based on the Inter-

national Nuclear Event Scale, similar to the Cher-
nobyl disaster on 26 April 1986 (3). Therefore, it
is not strange to consider to this earthquake as the
most important destructive seismic event of the
beginning of the twenty first century in the ad-
vanced industrial world.
Losses intensified by hit of the tsunami as the sta-
tistics shows it was more fatal (Fig. 1) and also
more buildings destroyed by its strike; However,
the quake was the main cause of the partial dam-
age of buildings (4). Figure 2 manifests the build-
ing losses distribution through affected areas and
Fig. 3 reveals the relative impact of the earthquake
vs. tsunami in each prefecture of Japan (4).
Fig. 1: Division of total 19100 death and missed
people by the reason as of 10th March 2012
(CATDAT)
Fig. 2: Building damage distribution (CATDAT)
Fig. 3: The relative impact of the earthquake vs.
the tsunami in each location

14
Seismology and Seismic History
This mega thrust earthquake is categorized as a
great earthquake with the magnitude more than 8
in scientific seismological classification (5). Over
1000 aftershocks, some of which were larger than
the recent catastrophic earthquakes in Iran such as
Bam, Iran 2003, hit the area since the main shock.
Regardless of the consequent tsunami, the To-
hoku Sendai Earthquake (2011) is the largest rec-
orded earthquake in the history of Japan in terms
of magnitude while the territory of Japan is known
by numerous and critical earthquakes. There are
two momentous calamitous earthquakes in history
of Japan: The great Kanto earthquake with magni-
tude of 7.9 on 1 September 1923 which destroyed
Tokyo and Yokohama rigorously by the severe
quake and subsequent fires and caused more than
143000 deaths (6, 7); and the Kobe earthquake
(also known as Hanshin- Awaji earthquake) with
magnitude of 6.9 on 17 January 1995 that left
more than 6400 demises (6, 8). The Kanto inci-
dent is still the deadliest earthquake in Japanese
history and the Kobe earthquake was the most
costly natural disaster of the world since Tohoku
Earthquake 2011 (9).
Methodology
Japan crisis management system
Japan has an overall population of 127 million and
is one of the most densely populated countries in
the world (340 persons per Km), where the popu-
lation highly concentrated around Tokyo (6). This

earthquake-prone country as a pioneer in crisis
management has a comprehensive plan for pre-
paring against disasters, consists of the Central
Council for Accident Prevention, chaired by
Prime Minister, set of cohesive rules for imme-
diate response to all of the unexpected incidents,
the advanced research system and the extensive
public education about disasters. As the result of
this plan, in the case of an accident, people, gov-
ernment officials and rescue departments know
exactly what to do while the alarm is sounded,
without chaos.
It was after the disastrous Kobe earthquake of 17
January 1995 (M6.9) that crisis management of
Japan greatly promoted since the government set
up a GIS system and a general computer network.
This system contains different subsystems to op-
erate all disaster related functions from prevention
before the disaster to damage evaluation after it
(10). Additionally, the most advanced earthquake
and tsunami early warning system of the whole
world is installed in Japan during 2003 to 2007,
which is one of the main parts of this crisis man-
agement system. This warning system had a con-
siderable role in Tohoku 2011 earthquake to re-
duce losses and save lives. Several Japanese media
such NHK channel and also mobile phone net-
works have the most responsibility of broadcast-
ing the news of early warning system.
In management of the 11 March 2011 crisis, one
of the most facilitative factors for emergency
managers was proper behavior of people who fol-
low the commands cautiously. In other words, the
“social capital” in this country had a significant role
in recovery after the incident as people’s high re-

spect to roles and moral values and their solidarity
prevent them from influx for aid and looting and
motivate them to consider the public benefits in-
stead of self-interests.
Response to the disaster
Immediately after the event, The Government of
Japan (GOJ) held National Committee for Emer-
gency Management, headed by Prime Minister.
The government declared an emergency in ef-
fected area and dispatched the Japan Self Defense
Forces for rescue operations (11). All ministries
and departments such as Foreign Ministry, Minis-
try of Transport and Ministry of Health were in-
volved in this response, also local offices of disas-
ter response in all prefectures begins their opera-
tions as their duty was already clear. The Ministry
of Health was in charge of preparing suitable ve-
hicles for supplying water and assigning hospitals
for remedy of casualties and people who have
been exposed to radiation. Ministry of Agriculture,
Forestry and Fisheries with Ministry of Finance
were responsible for providing food, portable toi-
let, blanket, radio, gasoil, torch, dry ice and other
15
essential things. By the command of the govern-
ment, all of the main highways in north of the
country were completely occupied for emergency
response activities. Besides, the transport systems

includes subway, shipping and the Shinkansen
bullet train ceased their activity in Sendai and To-
kyo instantly after the quake.
Moreover, at the day of event the Government of
Japan declared “the state of nuclear emergency”
due to the threat posed by reactors in two Fuku-
shima nuclear power plants (I and II) and 140,000
residents within 20 km of the plant evacuated. At
15:36 JST (Japan Standard Time) on 12 March,
there was an explosion in the reactor building at
Unit 1 in Fukushima Daiichi (I) power plant. At
11:15 JST on 14 March, the explosion of the
building surrounding Reactor 3 occurred. An ex-
plosion at 06:14 JST on 15 March in Unit 2, dam-
aged the pressure-suppression system. When the
disaster began on 11 March 2011, reactor unit 4
was shut down for periodic inspection and all fuel
rods had been transferred to the spent fuel pool
on an upper floor of the reactor building. On 15
March, an explosion damaged the fourth floor
rooftop area of the unit 4 reactor.
Japanese Red Crescent Society (JRC), which had
a substantial role in initial relief operations and
temporary housing, deployed its teams promptly.
JRC performed properly for accommodation of
refugees and evacuees in schools, public buildings,
and shelters. This society adapted its operations to
all other rescue organizations and NGOs, which
deployed to the area later.
Construction of temporary housing in quake-
stricken prefectures was begun 8 days after the
event and the first set of buildings was expected
to be ready within a month (12). In addition to
medical aids, therapists and social workers were
dispatched to the affected zone by Health ministry
and then in coming days the concentration of

treatments was shifting to psychotherapy from
physical sicknesses. In addition, this Ministry per-
formed required actions in order to control and
inhibit infectious diseases and encouraged people
to use masks (2).
Fire was reported in eight prefectures after the
quake. Fire suppression of gas pipeline took a few
days and fires in Cosmo Oil Installations and
some other refineries lasted 3 days. Generally, the
number of fires increased from 44 to 325 in a
week, but its growth rate declined. All the fires,
which were triggered after the earthquake, were
under control of Japanese Police and it can be said
that they could prosperously cease and extinguish
them (13). On the other hand, these fires and
breakdown of six out of nine oil factories faced
the affected areas with fuel shortage. The gas
pipeline repairing operation had a slow progress,
too. Therefore, about one million liter gasoline
per day had been carried to the damaged areas by
tankers and then by cargo train in order to com-
pensate lack of fuel. Low displacement capacity of
oil and coal shipments caused delays in delivering
fuel loads, which were importing from countries
such as South Korea and Russia, to consumers
(13).
Due to the shutting down of the power plants
which were cracked by the quake and tsunami,
authorities begun imposing sporadic power cuts
nationwide to make up for production losses.
Correspondingly, large factories like Toyota and
Sony halted their production activities and many
citizens in Kanto reduced their power consump-
tion in order to abridge the time of blackouts (14).

Nuclear crisis
There are 54 reactors in Japan, but since the tsu-
nami on March 2011 that destroyed Fukushima
plant (Fig. 4) and triggered the world’s worst nuc-
lear crisis in 25 years, the government did not al-
low to restart any reactor that have undergone
maintenance due to public safety (15). The first
nuclear power plant of Japan was initiated with
collaboration of English corporations in 1973, but
these kinds of power plants then developed by
American technology. All the 11 reactors in Fu-
kushima 1, Fukushima 2, Onagawa and Tokai nu-
clear power plants automatically safe shut down
after the quake; however, arrival of tsunami debris
with high waves damaged reactor’s cooling sys-
tems and eventually, resulted hazardous explo-
sions. This could have been prevented if the de-
signers had estimated the probable maximum alti-
tude of the tides more prudently. The explosion
16
occurred in 4 of the 6 reactors of Fukushima 1
power plant one after another, while the unit 3
reactor was more damaged and more intensively
contaminated the surrounding area. A few hours
before each of these explosions, authorities
warned about the cooling system breakdown, or-
dered to evacuate neighboring people and tried to
drop the pressure of vapors, but in all of them the
hydrogen explosion finally happened.

The owner of the Fukushima Plant, The Tokyo
Electric Power Company (TEPCO), is accused of
mismanagement and hiding the truth about the
real damage caused by the disaster at the expense
of saving the company (16). Moreover, according
to reports, it was expected that TEPCO safely
shutdown reactors of Fukushima 1 nuclear power
plant approximately a month before the 11 March
earthquake, but apparently the company avoided
this action because of economic issues.
Over 140 thousand residents were evacuated from
20 Km around the Fukushima plant. Radiation
penetrated in foods and drinking water in 30
kilometer far from the evacuated area, and au-
thorities inhibited distribution of these polluted
foodstuffs (13). U.S. Department of Energy an-
nounced a wide area beyond 80-kilometer radius
around the Fukushima plant is affected by radia-
tion (17).
The explosion of Fukushima power plant and its
aftermaths aroused public concerns about nuclear
energy in Japan and other earthquake prone coun-
tries. Consequently, other power plants, which
were not resistant to the probable future quakes
with magnitude more than 8, ceased they activity
gradually sequentially by the command of The
Prime Minister. TEPCO shut its last operating
nuclear reactor in 26 March 2012 for regular
maintenance, leaving just one running reactor sup-
plying Japan's creaking power sector (15). Then
again, on 10 April 2012 (less than a month later),
as the summer arrives, while Japan is going to
struggle with electricity shortage, the government
planned to restart one of the atomic plants in
Kansai after approval its safety (18) and faced
with people’s disagreement.

Furthermore, the nuclear crisis has led to growing
opposition against atomic power plants in other
countries, particularly in Germany, where thou-
sands of citizens participated in an anti-nuclear
demonstration. This disapproval also affected the
regional election results unbelievably. In the state
of Baden-Wurttemburg, which traditionally had
gone with Christian Democratic Union party for
58 years, most of people voted for the Green
Party who was against with 17 nuclear reactors in
this country (19).
Fig. 4: Fukushima 1 NPP explosion, 14 March
2011 (DigitalGlobe)
Results: Crisis consequences
The 11 March 2011 earthquake had many delete-
rious environmental impacts that take a long time
to recover. Apart from radioactive materials dis-
persed due to nuclear plant explosions and dis-
charging polluted radioactive water of cooling sys-
tems to the sea, the subsequent tsunami induced
huge amount of debris contains building materi-
als, broken boats, cars, trees and etc. that cause
environmental harmful issues.
Radioactive pollutions and radiations as the most
harmful repercussions of the earthquake induced
fear and concern among resident. Most evacuees
did not return to their home even after the safety
of the regions was assured. However, the govern-
ment tried hard to convince people to return to
their homes by checking and promulgation the

radiation doses constantly, but just the population
of old people gradually increased. Therefore, satis-
fying young people to come back will be a de-
manding challenge for the government.
17
• A year after the event, anecdotal evidence
suggests that fear of radiation, rather than
contamination itself, is triggering stress-re-
lated problems among nuclear evacuees (20),
despite the experts emphasized that the
doses are too low to develop cancer. Even
in more distant areas, where completely se-
cure, parents do not allow their children to
play outside. Although there have been no
recorded deaths from radiation in Fuku-
shima, according to the Yomiuri Shimbun
newspaper, psychological trauma associated
with evacuation, pneumonia and heart dis-
ease were much more fatal based on statis-
tics. Therefore, in months after the event,
Japanese Red Cross concentrated on mental
health issues.
• Also, the tsunami had adverse effects on ag-
riculture and requires long-term reconstruc-
tion at least for 2 or 3 years. In addition, the
fishing industry faced to critical continuing
problems. Most reports acknowledged that
Japan’s food exports could be limited by Ja-

pan’s current Production and supply short-
ages, along with boosting food safety con-
cerns and possible long-term radiation
threats to its food production, in contrast
possibly its need for food imports will in-
crease in future (21).
• Moreover, since Japan is a country covered
by jungles, wooden houses are very preva-
lent in this country and despite the dropping
rate of wood imports in recent decade, due
to boom reduction of this kind of homes;
the Tohoku earthquake caused a 70% rise in
wood import rate by enhancement of the
wood demand. This made a competition for
wood exporters from different countries
such as Australia, America, and China.
• One of the important impacts of the Fuku-
shima power plant explosion is its psy-
chological consequences. Regardless of
common diseases such as infectious ones
that break out after earthquakes, the radioac-
tive contamination permeated to the resi-
dential areas where people was living, work-
ing and planting brought a ten times fatal
disease, which is hopelessness and untruth-
fulness. People know they should leave any-
thing they had include home and agriculture
plant and this lead them to an ambiguous
future which is unstable and they should
build everything from beginning. The in-
crease in number of suicides in power
plant’s surrounding areas even far from
them and farmers concern about safety of

their productions and land even 100 kilome-
ters far from the affected zone prove the
strength and influence of this issues.
• Japan should also challenge with the prob-
lem of enhancing of unemployment. Large
number of refugee and evacuees left their
home and moved to other cities. Also,
workers of car and electronic factories are
now jobless by factory closure so they are
forced to immigrate (22). Japanese govern-
ment created around 20 thousands of jobs
in the emergency measures to combat the
effects of the disaster in a month, but the
number of the unemployed ones was much
more than created jobs (23). Additionally,
women especially in rural areas, who used to
were involved in tough works such as agri-
culture and fishing, after the disaster have to
work in other posts and try different occu-
pations in order to help to family economic.
Many of these women take apart in protests
against Fukushima power plant issues in
Tokyo in October and November 2011. It
seems that this earthquake has modified the
women life style in affected prefectures as
now they have more important roles in fam-
ily issues and it is big change in an almost
traditional male-dominated Japan.
• Following the shutting, the Fukushima
power plant, on February 2012, the House
Foreign Relations Committee off Japan ap-
proved to export its nuclear equipment to
Vietnam and Jordan. Also Japanese compa-
nies signed agreements with India, Bangla-

desh, and Turkey about construction, opera-
tion, and management of nuclear power
18
plants in these countries, despite environ-
ment activist’s oppositions in recent months
against these transactions and their high
costs and permanent detriments for humans
and earth. Actually, the nuclear power in
spite its approximate low costs, have many
hazardous disadvantages that the Japan 2011
accident and the Chernobyl 1986 are good
samples for this fact. Unfortunately, devel-
oping countries do not consider these con-
sequences and endanger the environment
and people’s lives while Japanese authorities
are just accenting their own country’s bene-
fits.
Conclusion
In Tohoku earthquake and tsunami of 11 March
2011 despite the unprecedented scale of the quake
itself, infrastructures and buildings mostly re-
mained standing and proved the resilience of Ja-
pan is planning laws especially in constructions
and earthquake technology. Hence, if the earth-
quake had been the sole problem, then Japan
could have claimed for itself a momentous pros-

perous in planning for the impact of a major
earthquake. The reason of Japanese plans failure
was the large-scale tsunami, which had higher
waves than what was assumed in designing. In
addition, the fact that Japanese authorities consid-
ered economic benefits more than safety and
moral factors exacerbate the situation. Even after
the disaster, this country just cared about eco-
nomic benefits and sought to export its technol-
ogy to other countries.
However, this disaster was a motivation for peo-
ple and governments worldwide to replace clean
energy with the hazardous one and it was a re-
minder to decommissioning the old and unsafe
operating power plants. Thus, the Metsamor nu-
clear power plant in Armenia, Iran’s neighboring
country, is a critical threat in the region with high
seismic risk. Governments had to plan long-term
and costly solutions to replace the nuclear energy
with clean and renewable forms of it with respect
to criteria and moral values, not only the benefits.
Although energy issues and management of power
plant’s crisis was a blind spot in Tohoku disaster
management, Japanese social ethics and their
manner in dealing with the problem were the
most advantageous points. Discipline, maintaining
calm, public confidence in managers and scientific
management based on the plans helped to im-
prove the situation more quickly (Figure-5). Long
queues of Japanese People for food and facilities
instead of chaos, which we mainly consider in de-
veloping countries, could be a good proof for
other countries that enterprising on educating
people about how to act in crisis is very operative
and effective in enhancement of disaster manage-

ment.
The 11 march 2011 earthquake was an alarm for
seismologist all over the world, particularly in Te-
hran as a capital city, to revise their methods and
evaluation of estimating the plausible time and
magnitude of earthquake. It could be an alarm for
us to be more meticulous and cautious about the
earthquake hazard as prepared and industrialized
Japan with the most modernized technology con-
fronted many extensive troubles, which were out
of their predictions. Now we should ask this ques-
tion “how much we are prepared in an earthquake
prone country with a capital located exactly on
active faults?”
Fig. 5: These two photos taken over a six-month period
showing aftermath of the March 11, 2011, tsunami and its
cleanup progress in Wakabayashi-ward in Sendai, Miyagi
Prefecture, in northeastern Japan. (pacificcitizen.org)
19
Ethical considerations
Ethical issues (Including plagiarism, Informed Consent,
misconduct, data fabrication and/or falsification, dou-

ble publication and/or submission, redundancy, etc)
have been completely observed by the authors.
Acknowledgments
The authors declare that there is no conflict of
interests. The authors appreciate the assistance of
IIEES and Tehran university colleagues for final-
izing this study, specially H.R. Jalilian, M.H Pisha-
hang and Z. Hejazi.
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Practice Article
How differently we should prepare for the next disaster?
Mineko Yamashita, RN, PhD1 and Chikako Kudo, RN, BScN2
1School of Nursing, Faculty of Health Sciences, University of
Human Arts and Sciences, Saitama-shi and 2East Japan
Railway Co., Tokyo, Japan
Abstract Following the Great East Japan earthquake (the Big
Quake) that hit the northeastern parts of Japan on March
11, 2011, aid was dispatched from multiple levels of
organizations including the Japanese Nurses Association
(JNA). Evidence indicates that the JNA did not play an effective
role in the aid efforts, since the professional
organization had pulled out and stopped sending nursing
personnel from the end of April 2011. In view of the
way that things were handled in terms of aid efforts
immediately, a year, or two years after the Big Quake
occurred, the authors of this paper have identified issues related
to nurse’s role at the time of the disaster. By

looking back at what happened, we have gained insights into
how to prepare for future disasters.
Key words community health nurses, disaster nursing, natural
disasters, Japan, earthquakes, the Great East Japan
earthquake, volunteer aid.
INTRODUCTION
As a result of the 9.0-magnitude Great East Japan earthquake
(the Big Quake), the northern parts of Iwate through to the
southern parts of Ibaragi were affected by a tsunami.The areas
destroyed extended some 500 km from the north to the south
along the Pacific Ocean, and 200 km from the east to the west
towards the interior. Some 16 000 people were estimated
dead, with 4000 people still missing in August 2011 (Matanle,
2011), as reported by the National Research Institute
for Earth Science and Disaster Prevention. The Institute
also confirmed that 62 municipalities over six prefectures
(Aomori, Iwate, Miyagi, Fukushima, Ibaragi, and Chiba) were
devastated by the tsunami (http://www.wpro.who.int/wpsar/
volumes/02/4/2011_Nohara/en/). The Miyagi Prefecture was
the worst hit by the tsunami, flooding 16% of towns and
villages (Miura et al., 2012).Thirty months after the Big Quake
as of August 2013, the statistics showed that some 15 883
people were dead, 2654 were still missing, and 289 611 people
were uprooted from their home towns to be dispersed
into temporary living quarters across the country (http://
www.wpro.who.int/wpsar/volumes/02/4/2011_Nohara/en/).
Consequently, many municipalities were left paralyzed in
terms of assuming administrative responsibilities. In the
midst of a chaotic situation with no definitive leadership
taken by the national government for the people, a number of
nonprofit organizations (NPO) started posting requests on
their websites for volunteers. The second author of this paper

decided to join a NPO since she had not been able to contact
her family who had lived close to the disaster sites. She
thought that going into the disaster-hit areas might serve two
purposes: contacting her family and helping the disaster
victims. Her activities from June through August 2011 are
summarized in Table 1. She was a senior in the post-
registered nurse (RN) program and had clinical experience.
The first author supervized a project to write about her expe-
rience (Kudo, 2012).
PROJECT REPORT
Volunteers joining the aid effort
Many of the volunteer workers did not tell their families or
friends that they were taking time off in order to join the aid
efforts in the disaster areas. They could have taken paid leave
but only if they disclosed the reason for their time off.
However, in fear of being persuaded not to go into the dis-
aster areas, they took unpaid leave for the purpose of joining
the aid effort.
The leader of the group from a NPO, which the second
author joined, was a Big Quake victim himself. He urged the
group members to take pictures of the disaster areas and to
put them on their website. His intent was to help those people
who had contemplated going into the disaster areas for the
purpose of helping to make their own “informed consent”
decision about entering the disaster areas to assist, based on
the information that had been updated on their organiza-
tion’s website on a regular basis from the disaster areas.
Community health nurses’ role
Interviewed by the first author, a group of the community

health nurses (CHNs) felt that their expertise was not fully
Correspondence address: Mineko Yamashita, School of Nursing,
Faculty of Health
Sciences, Ningen Sogo Kagaku Daigaku, [University of Human
Arts and Sciences],
354-3 Shinshoji Kuruwa, Iwatsuki-ku, Saitama-shi, Saitama
339-8555 Japan. Email:
[email protected]
Received 12 September 2013; revision received 29 November
2013; accepted 9
January 2014
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Nursing and Health Sciences (2014), 16, 56–59
© 2014 Wiley Publishing Asia Pty Ltd. doi: 10.1111/nhs.12131
http://www.wpro.who.int/wpsar/volumes/02/4/2011_Nohara/en/
mailto:[email protected]
utilized. They stated that they had not been given an oppor-
tunity to exercise their clinical judgment so as to prioritize
their plan for action (Yamashita, 2011). Instead, the CHNs
were instructed to “take care of the public” by their superior,
a male public servant who did not have a healthcare back-
ground. The CHNs, who were employees of the local govern-
ment, where the structure is hierarchical and bureaucratic
like the national government, were subject to their superior’s
directives.

Potential health hazards
Following the initial triage, the CHNs visited individuals
door-to-door to ascertain that they were safe and that they
would not require immediate medical attention. They also
conducted health assessment on those who were placed into
school gyms or community halls. People were cooped into
small spaces without means to protect their privacy. There
were no private rooms and partitions were made out of card-
board. They could not take a shower or bath for days or
weeks on end.
Shelter-related health hazards
The CHNs were on guard for potential health hazards, such
as infectious disease break-outs . They took vital signs of the
victims on a regular basis. Health problems, such as circula-
tory issues, soon surfaced. Many of the victims were farmers/
fishermen who used to have daily active routines prior to the
disaster. When they were placed into temporary housing in
strange environments, their activity levels dropped both
physically and mentally, which led to a decline in their health.
They sat on the gym floor for weeks or months doing nothing.
Mental health problems
Levels of victims’ social interactions dropped with few words
exchanged even between family members. Victims’ stress
levels increased even to harming self or others. An increase in
child abuse cases was noted in the disaster-hit areas. An
increase of 24% of child abuse was reported among the
victims, including those who had to be evacuated from the
radioactive areas. A total of 120 cases of child abuse occurred
in the disaster hit areas in 2012. The figure was twice as many
compared to the previous year, accounting for 40% of the total

cases of child abuse cases put together across the country
(http://www.plosone.org/article/info%3Adoi%2F10.1371%2
Fjournal.pone.0088885). The increase of child abuse could
have been attributed to the fact that the victims had no privacy
because they were housed in public facilities. Nonetheless, the
increase is alarming.
Coupled with the Big Quake and the tsunami, the
Fukushima nuclear power plant disaster involved a series of
equipment failures, nuclear meltdowns and releases of radio-
active materials. People who had resided in the radioactive
areas had to be evacuated immediately when the accidents
occurred at the nuclear plants. Farm animals and crops had to
be abandoned. Out of despair, some people started drinking
alcohol or developed mental health problems such as depres-
sion. Long-term absenteeism was noted in the employees
over 42 municipalities that were designated as radioactive
areas. Employees of the affected municipalities were over-
loaded because their coworkers were swept away by the
tsunami. Approximately 30% of the employees in some
municipalities reportedly died or were missing. As a result of
stressful workload, many were absent from work due to
mental health problems as shown in Figure 1 (Anon, 2013).
Some victims died by suicide, because they experienced
numerous losses – losing family member, separation from
their family members, losing homes or jobs, losing their live-
lihood such as cattle/fishing boats, being dispersed into tem-
porary housing in strange towns or cities, not knowing what
was to be expected of them on a daily basis, and high levels of
anxiety related to an unforeseen future (The Cabinet Office,
2013). Table 2 shows the number of suicides over the past
three years (The Cabinet Office, 2013).
Volunteer aid
At the time of the Great Hanshin-Awaji earthquake in the

Kobe area in 2005, some one million volunteers participated
Table 1. Volunteer activities that the second author undertook
in
two communities
Months
(2011)
Community A in
lwate Prefecture
(as volunteer worker)
Community B in
Miyagi Prefecture
(as volunteer nurse)
June Cleaning up and removing
junk at victims’ homes
July Cleaning up land and
planting plants/flowers
Infection control activities
Coordinating group
activities (crafts and
other recreational
activities)
August Infection control activities
continued
Assisting local health unit

teams
Figure 1. The numbers of people absent from jobs over 1 month
due to problems related to the Big Quake
Prepare for next disaster 57
© 2014 Wiley Publishing Asia Pty Ltd.
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjour
nal.pone.0088885
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjour
nal.pone.0088885
in the rescue efforts (Anon, 2011). However, at the time of
the Big Quake, the number of volunteers was a quarter of a
million. Four reasons were identified as contributing factors
to the decrease in volunteer numbers this time: (i) roads were
wiped out by the tsunami thereby leaving no means of trans-
porting people or goods to the disaster areas; (ii) towns or
municipalities were swept away crippling administrative
functions of receiving or directing personnel for rescue
efforts; (iii) those who wanted to volunteer their services had
to be self-sufficient, which meant they were responsible for
paying their transportation, for lodging, or for other expenses
incurred as a result of participating in their rescue efforts; and
(iv) the nuclear plants disaster influenced people’s decision
against joining in the rescue efforts for fear of their own
safety (Anon, 2011).
DISCUSSION
A lesson we learned from the Big Quake experience was that
the vertical structure of the Japanese Government was the
factor that prevented nurses from assuming a leadership role

in rendering aid to the disaster areas. Japan has three tiers of
government: national, prefectural, and municipal. Although
prefectural or municipal governments have their own gov-
ernance, they are subject to the directives of the national
government.
In order to allow nurses to utilize their expertise at the
time of disaster, we make a few recommendations are made
as follows. The professional bodies, nursing, and other
healthcare allied bodies, should lobby the National Govern-
ment of Japan so that the information is disclosed promptly
at the time of disaster. The Japanese Government should also
explain delays on reconstruction work to the Japanese people
as well as decontamination work near the nuclear power
plant. Even two years and eight months after the crisis at
Tokyo Electric Power Company’s Fukushima No. 1 nuclear
power plant broke out, about 150 000 remain evacuees
(http://www.wpro.who.int/wpsar/volumes/02/4/2011_Nohara/
en/). Their anxiety levels increase as the decontamination/
reconstruction work is further delayed. Urgent attention to
the mental health needs of evacuees is required.
Since the CHNs are the first contact for people seeking
help we also make some recommendations about CHNs.
The CHNs need to be involved in all aspects of care
The CHN’s role at the time of disaster should be made clear.
Their expertise should be recognized and utilized. Since
CHNs, work in towns or villages, know the community indi-
vidually or as groups through their regular contacts, it is
imperative that CHNs become involved in all aspects of dis-
aster care from the initial stage through recovery (Cox &
Briggs, 2004; Yamashita, 2011). In terms of prioritizing the
care of victims, people of high risk come first; that is, pregnant

women, people with pre-existing medical or mental health
problems, those who have severe and persistent mental dis-
orders, requiring extensive help due to lack of family and
social support, and those who are not ambulatory. It is crucial
for CHNs to assess and provide care as necessary on a long-
term basis. Scope of activities change as needs change.
Hospital nurses need to be in charge of organizing
aid efforts
Senior nurses should be in charge of designating their cow-
orkers to go to the disaster areas in order to work with and
care for victims. Arriving at disaster sites, hospital nurses
should function effectively in collaboration with CHNs who
are knowledgeable about the locale and people at disaster
sites.
Nurses, community or hospital, should be allowed to take
leadership in their areas of expertise. If nurses had taken a
leadership role at the time of the Big Quake, the severity and
the extent of damage or numbers of victims might have been
different. Since the CHNs know the community through their
regular contacts with those who require attention, they are in
a position to attend to those who require assistance in a
timely fashion.
Scope of activities changes as needs change
The CHNs may alter their regular activities in order to
accommodate newly detected needs of the community.
Instead of providing physical check-ups or well-baby clinics,
they may need to lead a group for grief work. Traumatized
directly or indirectly, people would be under duress and may
experience higher levels of anxiety. Stress management work-
shops may be beneficial for all ages. Group members would
be allowed to share their experiences, and to ventilate

thoughts and feelings. Since CHNs may have to alter their
practice to suit the community needs, many of their activities
may be outside the usual scope of practice. The CHNs’ learn-
ing needs should be identified and appropriate assistance
should be provided in the form of staff development on a
regular basis (Yamashita et al., 2009). The CHNs should
educate people about possible psychological effects of the
disaster. Therefore, CHNs may demonstrate that they have
the expertise and a strong commitment to public or private
welfare from the beginning until long after the disaster.
Table 2. Suicides related to the Big Quake
2011 2012 2013 (as of August)
Male Female Total Male Female Total Male Female Total
42 13 55 18 6 24 22 5 27
58 M. Yamashita and C. Kudo
CONCLUSIONS
A lesson learned from the Big Quake experience was that the
Japanese Government failed to disclose the necessary infor-
mation. Without this, people, lay or professional, were unable
to act effectively. In anticipation of the next disaster, the
healthcare professional should continue to lobby out to the
government so that they may obtain the information neces-
sary to assess the situation, plan for aid, and act for disaster
victims in a timely fashion.

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The
Daily Yomiuri 30 September 2013 (p. 1).
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2011.]
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6.html.
Cox E, Briggs S. Disaster nursing: new frontiers for critical
care. Crit.
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Koarai M, Okatani T, Nakano T, Kamiya I. Geographic
characteris-
tics of tsunami flooded area by the Great East Japan earthquake.
2011. [Cited 15 Feb 2014.] Available from URL: http://www
.gsi.go.jp/common/000064460.pdf
Kudo C. Joining the aid effort as a volunteer. Jpn. J. Nurs. Sci.
2012;
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Matanle P. The Great East Japan Earthquake, tsunami and
nuclear
meltdown: Towards the (re)construction of a safe, sustainable,
and

compassionate society in Japan’s shrinking regions. Local Envi-
ronment 2011; 16 (9): 823–847.
Miura N, Yasuhara K, Kawagoe S, Yokoki H, Kazama S.
Damage
from the great East Japan earthquake and tsunami – a quick
report. 2012.
The Cabinet Office. Suicide numbers related to the Big Quake
(as of
August 2013). [Cited 28 Oct 2014.] Available from URL: http://
www8.cao.go.jp/jisatsutaisaku/toukei/pdf/h2507/s3.pdf.
The National Research Institute of Earth Science and Disaster
Pre-
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http://
www.bosai.go.jp/ (in Japanese).
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Journal of Psychology and Theology
2007, Vol. 35, No. 4, 328-341
Copyright 2007 by Rosemead School of Psychology
Biola University, 0091-6471/410-730
328
Spirituality has been increasingly recognized asimportant 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 pro-
fessionals 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 fre-
quently used spiritual inter vention by Christian
counselors (Sorenson & Hales, 2002; Wade & Wor-
thington, 2003). Even practitioners working in secu-
lar settings regularly incorporate prayer into their
practices in some way (Ball & Goodyear, 1991; Mars-
den, Karagianni, & Morgan, 2007; Yoon & Black,
2006). For instance, such providers believe that pray-
ing 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 Sur vey
Research Associates, 2003). Christian clients, in par-
ticular, 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 pos-
itive 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 fac-
tors are related to client expectations.
PROBLEM BACKGROUND
Historically, religion and psychology have been
mutually exclusive disciplines, each field relying on
CHRISTIAN CLIENTS’ PREFERENCES
REGARDING PRAYER AS A
COUNSELING INTERVENTION
CHET WELD, ED.D
Casas Church, Tucson, Arizona
KAREN ERIKSEN, PH.D
Florida Atlantic University
Spirituality has increasingly become a consideration
for mental health practitioners. As a result, spiritual
interventions, including prayer, are now more fre-
quently used in counseling. However, no research
has explored Christian clients’ expectations regard-
ing prayer in counseling. This study surveyed first-
visit Christian clients and their therapists to ascertain
client expectations and therapist beliefs and prac-
tices. Analysis with two sample t-tests with unequal
variances, one-way analysis of variance, simple lin-
ear 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 includ-
ed in counseling; (d) they wanted counselors to pray

for them outside of session; (e) religious conserva-
tives had higher expectations for prayer than did lib-
erals; (f) clients with prior Christian counseling had
higher expectations of prayer than did clients with-
out. Research implications are discussed.
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.
[email protected]
WELD and ERIKSEN 329
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 (Ameri-
can 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 contro-
versial. While some mental health practitioners inte-
grate 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 per-
spectives challenge practitioners to rectify the con-
troversies. 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; Parga-
ment, 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, McCul-
lough, & Sandage, 1996). In addition, some guide-
lines have been established to help clinicians match
interventions with clients’ spiritual developmental
stages (Fowler, 1986; Griffith & Griggs, 2001; Wor-
thington, 1989).
Specialty fields have also evolved that offer guid-
ance to practitioners. For instance, within the Chris-
tian counseling specialty, studies have determined
what spiritual techniques are used by clinicians—
evaluating the client’s religious background, recom-
mending 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; Hole-
man, 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 inter ven-
tion in psychotherapy has received even less atten-
tion (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 posi-
tive 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 vali-
dated 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 inter-
vention (Ball & Goodyear, 1991; Carlson et al.,
2002; Gubi, 2004; Shafranske & Malony, 1990;
330 PRAYER PREFERENCES
Sorenson & Hales, 2002; Wade & Worthington,
2003; Worthington, Dupont, Berr y, & Duncan,
1988). For instance, Sorenson and Hales (2002) dis-
covered that 30% of Christian therapists pray with
clients during sessions. In Worthington, Dupont,
Berry, and Duncan’s (1988) study, therapists report-
ed using in-session prayer in 32.5% of sessions,
although it is unclear the degree to which their find-
ings 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 psy-

chologists prayed privately for clients, and seven per-
cent 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 organi-
zations believed praying with or for a client was appro-
priate (78% in Christian agencies and 100% in Chris-
tian private practices). In fact, praying with or for a
client was the most frequently used religious interven-
tion 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 expecta-
tions were related to spiritual interventions, including
prayer; or whether prayer was audible or silent.
More recently, Gubi (2004) surveyed 578 accred-
ited counselors in England to determine the frequen-
cy of use of various prayer interventions. Eleven per-
cent 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
a n a d j u n c t t o c o u n s e l i n g . F i n n e y a n d M a l
o n y
(1985b) evaluated nine clients to determine whether
contemplative or meditative prayer was associated
with improvement in psychotherapy. Results indicat-

ed weak support for prayer’s helpfulness to the coun-
seling process. Connerley (2003) conducted a dou-
ble-blind study of the effects of distant intercessory
p r a y e r a s a n a d j u n c t t o p s y c h o t h e r a p y w i
t h
depressed outpatients and concluded that interces-
sory 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 reli-
gious therapist as much as they rejected a less reli-
gious 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 incorporat-
ing the spirituality of clients. And theory literature
suggests ways to integrate spirituality with psy-
chotherapy. Integrating spirituality and psychology is
widespread among Christian counselors, among
whom prayer is the most commonly used spiritual

inter vention. 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 correlation-
al, surveying a convenience sample of clients seeking
counseling with Christian counselors and each of their
counselors. The research asked: What are the prefer-
ences of clients concerning the intervention of prayer
at faith based counseling agencies? Are there differ-
ences 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 interven-
tions—therapist intercessory prayer, silent in-session
prayer by the therapist, audible in-session prayer by
either the therapist or the client, prayer related home-
work, 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’ expecta-
tions 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 prac-
tices 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 strate-
gies 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 counsel-
ing session. Approximately 52% of clients complet-
ed 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 Cau-
casian, 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) report-
ed “other.” Of the 99% (N = 163) reporting on previ-
ous 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 charis-
matic/Pentecostal, 1% (n = 1) were Jewish, and 7%
(n = 11) listed “other.”
Therapists. Sixty-six percent (n = 21) of the thera-
pists 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 affilia-
tions were as follows: 56.25% (n = 18) non-denomi-
n a t i o n a l / e v a n g e l i c a l , 3 4 . 4 % (n = 11 ) m a i n l
i n e
Protestant, 6.25% (n = 2) charismatic/Pentecostal,
and 3.1% (n = 1) Catholic. The mean years in prac-
tice were 11.4 (range = 1 to 29; SD = 8.8; evenly
spread across number of years).
Procedures
After Institutional Review Board (IRB) permis-
sions were obtained, calls were made to identified
counselors to ascertain their willingness to partici-
pate. 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 complete-
ly anonymous, except that they identified their thera-
pist 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 sur veys 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 Thera-
pist Prayer Sur veys 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
b e g a n t h e i r p a r t i c i p a t i o n . S e c r e t a r i e s a t
t h e
researcher’s agency were given $25 or $50 gift certifi-
cates 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 partici-
pants 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 informa-
tion in extant research. Except for demographic
information, all survey items used a seven-point Lik-
ert-scale.
Items one through three constituted a “prayerful-
ness 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 com-
pared. 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 person-
al, 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 neces-
sary to avoid imposing counselor values on clients.
Items four and five stated: “I would like my coun-
selor 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 coun-
selor to pray for me outside of my counseling ses-
sions,” “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 coun-
selor 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 dupli-

cated standard items of interest on surveys. Informa-
tion 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 sam-
ple 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 coun-
seling 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. Partic-
ipants in the pilot study were asked to offer input for
incorporation into the final survey regarding the sur-
veys and their experience of taking the survey.
The Brief Therapist Survey. A brief survey that
paralleled the client sur vey as much as possible
w a s d e v e l o p e d f o r p a r t i c i p a t i n g t h e r a p i s
t s i n
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
sur vey in six other questions, altered to assess
t h e r a p i s t s ’ p r a y e r i n t e r v e n t i o n p r a c t i c e
s a n d
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
d u r i n g c o u n s e l i n g s e s s i o n s ,” “ I t h i n k t h a

t t h e
client should bring up the subject of prayer during
counseling sessions,” and “I assign prayer related
homework.”
Demographic items on the therapists’ sur vey
duplicated standard items of interest on sur veys,
items needed to fully describe the research sample.
Therapists were asked information related to gen-
der, 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 com-
puted 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
TABLE 1
Means, SDs, and 95% Confidence Intervals for Client and
Therapist Responses to the Prayer Survey Items
Survey Item Client N M SD 95% CI
Therapist

Prayerfulness Index (sum of next three items) Client 163 15.4
3.89 14.8, 16.0
Therapist 32 18.6 1.59 18.3, 19.4
1. Prayer is included in private life Client 164 5.3 1.67 5.1, 5.6
Therapist 32 6.7 0.51 6.6, 6.9
2. Client/counselor prays with other people Client 165 3.9 1.72
3.7, 4.2
Therapist 32 5.4 1.23 4.9, 5.8
3. Client/counselor agrees with the definition Client 164 6.1
1.44 5.9, 6.3
of prayer Therapist 32 6.7 0.51 6.6, 6.9
4. Counselor should bring up prayer Client 162 4.9 1.80 4.6, 5.2
Therapist 32 5.1 1.37 4.6, 5.6
5. Client should bring up prayer Client 163 3.8 1.81 3.6, 4.1
Therapist 31 4.2 1.00 3.8, 4.5
6. Counselor should pray outside of session Client 161 6.0 1.51
5.8, 6.2
Therapist 32 5.5 1.14 5.1, 5.9
7. Counselor should pray silently in-session Client 159 5.0 2.05
4.6, 5.3
Therapist 32 5.4 1.04 5.1, 5.8
8. Counselor should assign prayer homework Client 163 4.3
2.11 4.0, 4.7
Therapist 31 4.0 1.34 3.5, 4.5
9. Client desires/therapist uses audible prayer Client 162 4.9
2.19 4.6, 5.3
in-session Therapist 32 5.5 1.3 5.0, 5.9

10. Counselor should pray audibly Client 118* 5.7 1.33 5.4, 5.9
11. Client should pray audibly Client 117* 3.6 1.75 3.3, 3.9
12. Client and counselor should take turns Client 118* 3.8 1.94
3.5, 4.2
praying audibly
13. Counselor should stop at any time to Client 134* 5.2 1.86
4.9, 5.5
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.
question, eighty-two percent (N = 133) scored from
3 (Sometimes but Infrequently) to 7 (Always)
[6.7% responding with 3 (N = 11), 15.8% respond-
ing with 4 (Occasionally) (N = 26), 7.3% respond-
ing with 5 (Often) (N = 12), 9.1% responding with 6
(Almost all the time) (N = 15), and 41.2% respond-
ing with 7 (N = 68). Also noteworthy was that thera-
pists scored higher than clients did on all parallel
sur vey 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 deter-
mine significance of differences. Among the clients
who would be less likely to want audible prayer were
those who had not received prior Christian counsel-
ing, 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 coun-
seling wanting audible prayer and 76% (n = 68) of
those who had had no prior Christian counseling
wanting audible prayer. Differences were also signifi-
cant between religious affiliations groups (p = 0.001).
Ninety four percent (n = 64) of nondenomination-
al/evangelicals, 92% (n = 11) of Baptists, 83% (n =
39) of mainline Protestants, 100% (n = 3) of charis-
matic/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 nondenomination-
al/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 “lib-
eral” (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 liber-
als desiring it. Also, although not a significant differ-
ence, 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 sur vey 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 col-
lapsed into Protestant, Catholic, non-denomination-
al/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 sig-
nificant between Catholics and the other groups on
several items, and between Protestants and non-
denominational/evangelicals on one item.
Differences also existed when the four religious

affiliation groups were further collapsed into conser-
vative or liberal groups, with religiously conservative
clients scoring higher (prayerfulness M =16.3; item
M r a n g e d f r o m 3 . 6 t o 6 . 5 ) t h a n l i b e r a l c l i
e n t s
(prayerfulness M = 15.4; item M ranged from 3.6 to
6.2) on the prayerfulness index and on 11 of the 13
i t e m s . U s i n g a t w o - s a m p l e t - t e s t a n a l y s i
s w i t h
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 expect-
ed to more highly value its inclusion; they might also
experience greater comfort with spiritual interven-
tions more generally as a result of their prior experi-
e n c e s . F u r t h e r, r e g a r d i n g h i g h e r c o n s e r v
a t i v e
desires for prayer, Worthington and Gascoyne
(1985) found that conservatives more than liberals
expect greater use of religious interventions such as
TABLE 2
One-way Analysis of Variance of Client Prayer Intervention
Preferences by Religious Preference
Survey Item Protestant Catholic Nondenom* Baptist F p

n M n M n M n M
SD SD SD SD
Prayerfulness Index (total of next three items) 46 16.0 13 13.4
72 16.6 12 14.9
3.4 4.0 3.1 3.3 3.74 <0.022
1. Prayer is included in private life 46 5.4 13 4.9 72 5.8 12 4.7
1.5 1.9 1.4 1.6 2.95 <0.04**
2. Client prays with other people 47 4.0 13 3.1 72 4.4 12 3.7
1.8 1.3 1.6 1.8 2.70 <0.052
3. Client agrees with the definition of prayer 47 6.5 13 5.4 72
6.4 12 6.6
1.0 1.7 1.1 0.9 3.43 <0.021 & 2
4. Counselor should bring up prayer 46 4.8 12 4.1 71 5.6 12 4.7
1.7 2.1 1.4 1.5 5.13 <0.012 & 3
5. Client should bring up prayer 47 3.6 13 3.1 71 4.3 12 3.9
0.08
1.7 2.3 1.7 1.7 2.28
6. Counselor should pray outside of session 47 6.1 11 4.5 71 6.6
12 5.7
1.2 2.4 0.8 1.2 10.49 <0.00011 & 2
7. Counselor should pray silently in-session 45 4.7 13 4.1 71 5.6
12 5.2 3.05 <0.04***
2.2 2.5 1.7 1.3
8. Counselor should assign prayer homework 47 4.4 12 2.4 72
4.8 12 5.3
2.1 2.0 1.8 1.8 6.04 <0.0011, 2 & 4

9. Client desires audible in-session prayer 47 5.1 12 3.5 71 5.7
12 5.2
2.1 2.3 1.8 1.7 4.54 <0.012
10. Counselor should pray audibly 36 5.8 7 4.7 58 5.8 10 6.1
0.14
1.2 1.9 1.3 1.2 1.84
11. Client should pray audibly 36 3.9 7 2.9 57 3.6 10 3.5 0.58
1.7 1.3 1.8 2.2 0.65
12. Client and counselor should take turns 36 4.2 7 2.8 58 3.8
10 3.8 0.37
praying audibly 1.9 1.5 2.0 2.3 1.05
13. Counselor should stop at any time to 46 4.7 13 2.3 67 5.3 12
5.5
pray audibly 2.2 1.6 1.9 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.
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, non-
denominational/evangelicals, Baptists, and charis-
matic/Pentecostals would be expected to desire
prayer interventions more than Catholics or for sim-
ilar reasons, as these groups are generally more reli-
giously conservative than Catholics.
Clearly, regardless of differences among groups,
at least a majority and in some cases almost all Chris-
tian clients of Christian mental health providers

desired and expected audible prayer to be part of
counseling services. Yet some authors express con-
cerns that praying audibly with clients risks confu-
sion 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. Per-
haps, 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 counsel-
ing 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 & Wor-
thington, 2003; Worthington et al., 1988). The dif-
ferences 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 counsel-
ing. Client means on expectations of all prayer inter-
ventions measured by the survey items were high.
They almost always responded with at least “Occa-
sionally” (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 “thera-
peutic” lives, not just their personal lives.
These results may pose no problems for Chris-
tian 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 coun-
selors. 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, thera-
pists 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 interven-
tions 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. Thera-
pists 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). Appar-
ently, 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) intro-
duce 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, Kirk-
patrick, Hecker, and Killmer (2002) that clients pre-
fer that counselors should be the one to bring up
the subject of spirituality. Stating that this opinion
w a s c o n t r a r y t o c o n v e n t i o n a l w i s d o m , t h e
s e
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 fur-
ther 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 prayerful-
ness and client means on six prayer related interven-
tions. Client prayerfulness was moderately related
to client expectations on all six prayer-related inter-
ventions. (range of r from .40 to 58; p = .0001 on all
c o r r e l a t i o n s ) . T h e c o r r e l a t i o n b e t w e e n c
l i e n t
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 analy-
sis 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 home-
work,” 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 ther-
apist 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 interven-
tions to be included in Christian counseling.
Results of Other Exploratory Analyses
Age. Explorator y analyses were conducted to
examine the possible influences of demographic dif-
ferences. In addition to the differences noted above
with respect to prior counseling and religious affilia-
tion (including our recoding to conservative and lib-
eral 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 dif-
ferences 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 cor-
rections 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 prefer-
ence 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).
U s i n g t h e Pe a r s o n c o r r e l a t i o n , e x p l o r a t o
r y
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. Thera-
pists may thus do well to demonstrate special sensi-
tivity to the younger age group, as they may be less
likely to welcome prayer interventions, while avoid-
ing 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). Con-
sidering that two-thirds of both the therapist and
c li ent 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 counsel-
ing, 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)
A d d i t i o n a l l y, s u r v e y s c o n d u c t e d b y T h e B
a r n a
Group (2004) have found that females are more like-
ly 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 instru-
mentation, procedures, the convenience sample,
and the culturally limited sample. The study used
unvalidated instruments because no validated instru-
ments existed to measure client expectations or ther-

apist beliefs about prayer in counseling. Further,
because of the time involved for first-visit clients to
complete intake information, the survey was neces-
sarily brief. Future research could validated the mea-
sures 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 con-
fidence that results can be generalized to all Chris-
tian 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 reli-
gious 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

Iranian J Publ Health, Vol. 41, No.6, Jun 2012, pp.12-20 .docx

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