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When the couch is more than a couch

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Do therapists’ offices affect the therapeutic process?

By Anne Ptasznik

Psychiatrist and psychoanalyst Dr. David Dorenbaum says that to facilitate the “theatre of the mind” that occurs during therapy, it’s important to create a “potentiality of space.” “It’s no different than the space where children play, a place of fantasy, a place of creativity, a place we go that opens up opportunities of possibilities,” he says.

For years, the Freudian analyst’s couch was the iconic symbol for what a therapist’s office looked like. But today, as therapeutic approaches have evolved, it’s timely to consider how therapists’ offices are changing and whether office design and décor affect the therapeutic process—and even outcomes.

Dorenbaum’s office has changed since he inherited it from a respected colleague, whose tastes for shaggy carpet, wallpaper and thick curtains differed from his own. Guided by an associate, then-head of stage design for the Canadian Opera Company, Dorenbaum transformed the office—painting the walls white to appear more spacious, replacing the overhead glaring lighting with a softer floor lamp and installing window coverings that allow clients to look out while preventing anyone from looking in.

Appearing like a stage actor himself, Dorenbaum walks around his office, dramatically narrating the origin and significance of each décor item. The tall roll-top desk, designed by famous Italian designer Aldo Rossi, allows him to take notes standing up after sitting with clients all day. Shaped in the form of a lighthouse, it has the signification of “safety, of signaling the arrival at the port of destination,” he explains.

His ergonomic chair requires his body to be engaged, thus, in effect, becoming a work instrument that enables him to sustain attention. This he compares to Anna Freud practicing analysis while knitting in her rocking chair, which reportedly sharpened her attention. Paralleling the evolution of psychoanalysis, Dorenbaum is not the classic “speculative, silent, withdrawn” analyst, pretending to be a “neutral screen,” but rather a more active listener.

The chair, positioned behind the couch, helps to “liberate the gaze” so clients can say whatever is on their minds, without seeking approval through a nod or a smile. The couch is an armless black Eames chaise, originally designed for Academy Award–winning actor Billy Wilder, where clients say things they didn’t know they had the words to express. “The couch, rather than simply being a piece of furniture, is the invitation to go beyond language to signify that here you can talk and won’t be judged,” Dorenbaum says.

Psychoanalyst Dr. David Dorenbaum provides a “safe space for exploration” that focuses on his clients’ internal changes. (Photo credit: Nancy Leung)

Dorenbaum now rarely changes anything in his office in order to ensure that the focus remains on his clients’ internal change, rather than external change imposed by introducing new objects or moving old ones.

This mindful approach to design is one that Dr. Katherine Morris, a Maryland psychologist, recommends all therapists take, otherwise they risk “acting out” in their space. For example, a therapist with low self-esteem may inadvertently try to build himself up, for example, by plastering a wall with diplomas and displaying books he has written or photographs of important people he knows.

Through her design business, Morris uses depth psychology, which examines unconscious influences in our lives, to help her clients organize their offices better. Morris recommends that therapists, in the company of a colleague, reflect on their space and the feelings, thoughts and fantasies they might prompt in their clients. Expensive furniture, the space’s public or private feel and the presence of family pictures, for example, impart information about the therapist. Viewing personal items or bumping into a family member in a home-based office could even blur professional and personal boundaries, according to psychoanalyst Karen J. Maroda, who advocated against home offices in a 2007 article in Psychoanalytic Psychology that provoked heated debate. Therapists, Morris says, should sit in the client’s chair to see their visual perspective and even go outside to see what it is like to walk into the space.

But it’s not just intuitive. The cutting-edge field of neuroarchitecture is beginning to provide brain evidence for why we respond the way we do to spaces. Dr. Margaret DeCorte, a psychologist with the Royal Ottawa Mental Health Centre in Ottawa, Ont., explains that when people are in a vulnerable state, higher-level brain functions like cognition are compromised, and the limbic system, the “emotional brain,” is more sensitive, responding faster to natural elements in the environment. Dr. Roger Ulrich, a leader in the evidence-based design movement, argues that this is because as a genetic carryover of evolution, the brain easily processes natural elements in the environment, whereas the built environment requires more processing, thus increasing subjective levels of stress.

Control over the environment, for example, being able to dim lights or choose where to sit, enhances client satisfaction. (Photo credit: Anja Kessler)

Based on this work, DeCorte offers suggestions for how therapists can create a more healing space. The ideal office would have windows that look out onto elements of nature, such as a garden; it would feature soothing natural wall colours and artwork depicting nature scenes. Therapists can also create a more soothing space by placing a plant or other natural feature in a corner because 90 degree angles do not exist in nature, says DeCorte. Clients should sit facing the doorway with their backs to the wall because humans are “pre-wired” to feel safer that way. Flexibility and control of the environment also enhance satisfaction with the space, so having a blanket available for a client who feels cold and furniture that can be reconfigured spatially by the client are helpful.

Another important environmental feature is lighting. DeCorte says that dim lighting is best because overly bright lights make eyes constrict, which could be perceived as hostility, whereas low light dilates the eyes, making people appear friendlier. A 2006 study in Environment and Behavior found that dim lighting in a counselling room yielded more pleasant, relaxed feelings, more favourable impressions of the interviewer and more self-disclosure than did bright lighting.

But for most people, the relationship with the therapist outweighs any design issues. In a CrossCurrents survey of consumer experiences of therapist offices, one respondent said that in his five years of therapy, the setting has never made a difference. “When the connection between the therapist and the consumer is right, nothing else really matters to me,” he wrote.

Still, comfort, safety and privacy are important features of the therapeutic environment, as well as being, as Dorenbaum says, a “space for exploration.” DeCorte agrees, saying that the human brain develops according to a universal need for both. “We want sanctuary so we feel safe. But we also want a little element of opportunity.”

 

Crossing the threshold: What clients want in a therapy office

The therapist’s space “acts like a container for everything that happens in therapy. When you open up and share, it is like the office is ‘holding’ parts of you. That needs to feel safe and secure.” That’s how one consumer described the importance of the therapy space in a CrossCurrents survey. But how exactly can therapists create that safe physical space? Here’s what consumers and therapists told us:

Cozy or clinical. Most consumers favoured a cozy feel. “If it’s too clinical, I’m uncomfortable, but if it’s too homey, I lose confidence in the therapist’s professionalism,” wrote one consumer. While some therapists preferred a minimalist look, others advocated a balanced approach: “Therapists’ efforts to be bland in decor can backfire by not communicating and validating the fullness of human experience beyond what is purely instrumental,” wrote one therapist.

Picture perfect. Some therapists display personal photos because it presents them as “more human,” but some consumers and therapists considered it a boundary breach. “There shouldn’t be family pictures because that can be alienating for clients who feel alienated from their own families,” wrote one consumer.

In the hot seat. Seating is a big issue. “Comfortable chairs are a symbol of respect, conveying a willingness to listen and not rush the client,” wrote one consumer. For another, “I feel intimidated if the therapist sits higher than me. And separation by a desk can be intimidating.” One therapist wrote, “Provide more than one chair so the patient can choose where to sit and has an easy get-away so they don’t feel trapped.” Size also matters: One therapist, who specializes in eating disorders, highlighted the need to have chairs that fit both large and small bodies.

Good housekeeping. Tidiness is important. “I had a psychiatrist whose office was always dusty and the garbage was overflowing,” wrote one consumer. “This told me his patients aren’t important to him.” Clutter can be distracting, even anxiety-provoking: One therapist who specializes in anxiety wrote, “I’m conscious of keeping my space tidy so anxious clients don’t feel crowded and overwhelmed.”

It’s the little things that count. Consumers appreciated little touches like pillows, tissues and water—“crying can be dehydrating,” one consumer pointed out. Plants are another calming feature, but one therapist cautioned, “Badly cared for plants will make patients feel they will be badly looked after as well.” Another tactful touch: “There are two clocks in my therapist’s office—one visible to each of us so we both know the time and aren’t surprised when the session is over.”

A matter of degree. Consumers were divided on the issue of displaying credentials. “Displayed diplomas affirm we are in good hands and can affirm the overall professionalism of the experience,” wrote one consumer. Another added, “A few diplomas are okay, but a wall of them can be intimidating. I sometimes feel the therapist is trying to create a divide—to reinforce the well professional vs. ill patient dichotomy—for their own needs.”

The art of healing. Art is tricky because it’s subjective. “Don’t have art that could be threatening to someone who feels vulnerable, although almost any image could be interpreted negatively,” wrote one consumer. “But a good therapist could explore what was behind the trigger, so I don’t think therapists ought to try for complete neutrality.” One therapist who sees clients with eating disorders agrees: “I have a print of a Modigliani nude. Anything in your office might raise questions, so be prepared to discuss it.”

Respect diversity. “I am Inuit, and if I see culturally relevant objects, I know the therapist is aware of my heritage,” wrote a consumer. But another cautioned against tokenism and ignorance: “Clients can feel uncomfortable when clinicians misuse culture-based art or symbols as decoration for offices in an attempt to demonstrate inclusiveness.”

God and politics. “Avoid items that are overtly oppressive, including faith affiliations and heterosexist bias,” wrote one therapist. That includes politics. “A social worker where I did residency had a ‘Bush Sucks’ poster in her office,” wrote one therapist. “At that time, the majority would’ve agreed with her, but take into consideration she’s going to get people that disagree as well.”

Hema Zbogar

 

Safe spaces in ordinary places

Some front-line workers, particularly those who do street outreach, meet clients outside an office. But creating a safe, welcoming environment is still important. Judy Graves, a housing advocate in Vancouver, and Dr. Vicky Stergiopoulos, psychiatrist-in-chief at St. Michael’s Hospital in Toronto, offer these tips for creating safe spaces for meeting clients on the street.

  • Be aware of the power differential. Do everything you can to empower clients; sit down if they are lying on the street and avoid titles and jargon.
  • Consider continuing the conversation on a park bench, a community centre or an outreach van.
  • Meet homeless clients in the evening or in the middle of the night when they may be more relaxed and have greater privacy.
  • Treat clients to a meal if possible at a restaurant where they feel comfortable because marginalized people can sometimes be distracted and unfocused due to hunger.
  • Leave space for clients to get away. Be respectful and take extra care to be non-threatening.
  • Speak gently, go slowly because many homeless and marginalized people experience post-traumatic stress and require time to bridge out of dissociative states so they can focus beyond panic reactions.
  • Be flexible. People who are disaffiliated may only tolerate five to 10 minutes of interaction at a time. It may take several visits to obtain someone’s complete history.
  • Get clients laughing with you, for example, by playing kick-the-can in the alley or singing a bit of a song together. “Laughter, playing, singing all create equality between people and bring hope of things getting better,” says Graves.

 

Therapy by design

Alice Liang, principal at Montgomery Sisam Architects in Toronto, recommends these design strategies to create calm, intimate therapy spaces.

  • Natural light with windows, preferably with a view of nature.
  • Diverse lighting sources, including residential-type ceiling fixtures and softer table lighting, not fluorescent ceiling lights.
  • Warm and textured materials for the floor, wall and ceiling finishes.
  • Soothing colours with bright, cheerful accent colours for an uplifting ambience that considers social, cultural and individual preferences. (Bright colours are associated with positive emotions, dark colours with negative ones. Violet and blue hues decreased blood pressure, and warm colours, including red and orange, increased these biological functions, according toa 2001 literature review in the Journal of Counseling and Development).
  • Simple, non-cluttered residential or hospitality-styled furniture that is the right size and scale for the room.
  • Non-hierarchical arrangement of chairs, i.e., next to each other, not across a table, to avoid emphasizing the therapist’s “authority,” and for groups, the “equitable concept” of the healing circle.
  • “Positive diversions,” such as soothing landscape paintings and aquariums, plants or plant motifs on walls.
  • Quiet enhanced by “white noise” and programmed relaxing music in the waiting area.