Effective therapy typically begins with the establishment of an effective therapeutic relationship, also called a therapeutic alliance. The therapeutic alliance can have a profound effect on treatment process and outcomes. Research consistently demonstrates that the therapeutic relationship is the best predictor of therapeutic outcome (Horvath & Symonds, 1991; Orlinsky, Rønnestad, & Willutzki, 2004). Research also indicates that incorporating spiritual issues in the treatment process can facilitate or complicate the relationship building process (Morrison & Borgen, 2010). Accordingly, relationship building and maintenance are critical in the practice of spiritually oriented psychotherapy. In addition, resistance and countertransference are not uncommon in spiritually oriented psychotherapy and are essential in fostering client progress and reducing premature termination. This chapter focuses on the development and maintenance of an effective relationship. It begins with a discussion of establishing an effective therapeutic relationship. Then, it describes the importance of maintaining that relationship and discusses the ways in which resistance and countertransference are present in spiritually oriented psychotherapy and strategies for dealing with these processes. Finally, it illustrates key points in a case example.