Abstract
Research suggests that the softness, personalization, and order of the interior design elements of an office might affect appraisals of its psychotherapist. This research examines whether these perceptions are stable across students’ judgments in three cultures: the United States, Turkey, and Vietnam. Participants in each country responded to 30 color photographs of psychotherapists’ offices viewed from the client’s perspective, rating the quality of care and comfort expected in each office. Analyses revealed strong correlations between responses by participants from each country. Perceived quality of care and comfort improved with increases in office softness/personalization and orderliness. Analysis of the reported reasons in making judgments confirmed the importance of these dimensions. Future research could test the consistency of these responses to broader and more diverse sets of respondents and offices. The findings suggest the potential value of psychotherapeutic environments that are soft/personalized and orderly.
Keywords
Does the perception and evaluation of psychotherapists’ offices by university students vary across culture, even with increasing Westernization? 1 Cultures have values; they organize and shape the responses of inhabitants to a wide variety of social phenomena, including use of therapy (e.g., Gerstein, Heppner, Ægisdottir, Leung, & Norsworthy, 2009). Dimensions of culture have also been linked to personality traits (G. Hofstede & McCrae, 2004), and some have argued that the five-factor model of personality (neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness; Costa & McCrae, 1992) has cultural universality (McCrae & Costa, 2003). Culture may also influence the evaluation of the built portion of the environment (Brislin, 1983), but some environmental judgments may transcend cultural influence (Home, Bauer, & Hunziker, 2010) as has been argued with respect to the natural environment (e.g., Kaplan, 1995). In that regard, van den Berg, Vlek, and Coeterier (1998) discuss the consensus assumption, in which “similarities in responses to natural scenes outweigh the differences across individuals, groups and cultures” (p. 114). The extent to which people in diverse cultures have similar evaluations of the built environment, here, psychotherapists’ offices, could extend the consensus assumption to aspects of the built environment.
To support a consensus assumption, one must first show that cultures differ. Through enculturation and socialization, people develop similarities in behavior within cultures and differences in behavior across them (Berry, Poortinga, Seagall, & Dasen, 2002). Models of cultural comparison have been proposed, including those of Hofstede and Schwartz. Hofstede argues that cultures differ along five dimensions and substantiates this conceptualization with extensive research involving 50 countries and 3 regions (G. Hofstede, 1980, 1991, 2001; G. Hofstede & Bond, 1988). Examples of Hofstede’s five dimensions include individualism-collectivism and masculinity-femininity. Schwartz focused on motivational domains (e.g., power, achievement, conformity) argued to provide meaning to life. These motivations were exhibited across cultures (Schwartz, 1994a), but the relative balance of the motivations differed between cultures (Schwartz, 1994b). Despite conceptual differences and variability in the number of value dimensions postulated in current theories of cultural value orientations, there is a substantial overlap in cultural value orientation models and agreement that cultural value orientations are slow to change (Schwartz, 2011). Typically the models contain some conceptualization of the idea of egalitarianism as opposed to a hierarchical order of authority and the idea of the autonomy of the individual contrasted with the degree of embeddedness within social groups.
In the present research, reference to Hofstede’s data for the United States, Turkey, and in his later work, Vietnam (G. Hofstede & Hofstede, 2005; www.geert-hofstede.com) is cited to introduce the idea of differences between these cultures, rather than to pose specific hypotheses about the built environment based on Hofstede’s dimensions. The United States, Turkey, and Vietnam, the source of the cultural comparisons in this article, differ significantly on Hofstede’s dimensions, with Turkey and Vietnam closer to each other than they are to the United States on all but one of the dimensions (G. Hofstede & Hofstede, 2005). The most pronounced differences are evident for the dimension of individualism, where the United States is very high, and Turkey and Vietnam have the lowest scores for any of their ratings. From these cultural differences, we derive some sense of the relationship of these cultures with one another on value orientations.
Draguns and Tanaka-Matsumi (2003) present a case for exploring Hofstede’s dimensions to psychopathology, discussing this from a universalist (similarities across) and relativistic (differences within) approach to culture that could also be related to the dichotomy of etic (knowledge from outside the culture) and emic (knowledge from within the culture) approaches. These authors offer predictions about how Hofstede’s five dimensions would be manifested in psychopathology; yet these predictions do not offer guidance about reactions to the physical environment. Instead, the authors say that the cultural context and milieu in which the encounter between patient and diagnostician takes place needs research.
Beyond the domain of the psychotherapist’s office, research and writing has pointed to the role of cultural differences in built forms (e.g., Lawrence & Low, 1990; Rapoport, 1969). In particular, in Rapoport’s early work, he discussed the role of a variety of “social, cultural, ritual, economic, and physical factors” in influencing the varied physical form of the built environment across cultures (1969, p. 47). Lawrence and Low (1990) suggest that built forms, spanning generations, “become important repositories of cultural information” (p. 492). More recently, Rapoport (2008) has emphasized universals or constants in the expression of culture, such that culture is not “completely variable” (p. 17) and argues that only through research can the role of culture for a particular situation be determined. Questioning whether culture may play a role in nonresidential environments, Rapoport (2008) suggests that culture is likely to be minimal in such settings as airports, scientific laboratories, office buildings, and athletic arenas, among other facility types. He also notes that this hypothesis may be wrong and states that research in nonresidential settings is badly needed. In his view, and germane to the research here, the scale of the setting may be relevant in reflecting the role of culture. Using the office buildings as an example, he suggests that the interiors “might well vary with culture” (2008, p. 21).
To put the experience of the physical environment in context for Vietnam and Turkey, which may be less well known to readers than the United States, some comparative data may be informative. World development indicators (World Bank, 2012) show the United States at one end of the developed continuum and Vietnam at the other; Turkey varies in closeness to the United States and Vietnam, depending on the indicator. For 2011 data, for example, the urban population, as a percentage of the total population, was 82% in the United States, 71% in Turkey, and 31% in Vietnam; the health expenditure per capita in current U.S. dollars was 8,608 in the United States, 696 in Turkey, and 95 in Vietnam. Perhaps reflecting increasing globalization and more commonality, the number of Internet users per 100 people was 77.9 in the United States, 42.1 in Turkey, and 35.1 in Vietnam.
Attitudes Toward Mental Health and Counseling Environments in the Three Countries
Not only do these three countries differ on cultural dimensions, such as those of Hofstede, and the degree of urbanization and development, with implications for the experience of space, but they also differ in availability and use of mental health services. This variability is another reason to expect differences between participants from the United States, Turkey, and Vietnam. In Vietnam, the vast majority of the limited mental health resources are used on severe illnesses such as schizophrenia (Ng, Than, La, Than, & Dieu, 2011). There is a stigma associated with mental illnesses such as depression, and acknowledging that you have depression has been considered a personal failure (Wallace, 1997). In the view of Zinman-Schwartz, who operated a free psychotherapy clinic in Ho Chi Minh City, the idea of a psychotherapy practice was essentially unknown in Vietnam until relatively recently (Paterson, 2006). The family is viewed as the center of Vietnamese life (Paterson, 2006), and unless the behavior is unmanageable by the family, as may be the case in severe conditions (Wallace, 1997), formal mechanisms such as counselors are avoided.
In research comparing Vietnamese students (ages 18-50 years) who were refugees enrolled in a community college in the United States and Anglo-American students (ages 17-51 years), the Vietnamese students not only had less positive attitudes toward seeking psychological help and less confidence in professionals to address mental health issues, but also were more concerned with the stigma associated with seeking help than were their Anglo-American counterparts (Atkinson, Ponterotto, & Sanchez, 1984).
We have found no published research describing the kinds of physical environments in which counseling and psychotherapy takes place for adolescents in Vietnam. In the context of the school environment, it may take place in offices that are sparsely furnished with cement walls, if construction follows typical practices. Counseling services often do not have an official position within the school hierarchy, nor are the counselors legally regulated (Le, 2009); for that reason, it is unlikely that the material resources, such as spaces devoted to that function alone, are provided for their counseling work.
The literature suggests that few Vietnamese participants in this study would have direct experience with a psychotherapist’s office, certainly one with Western furniture. Data from a World Health Organization assessment of mental health in Vietnam (WHO, 2006) suggest that mental health services have been provided primarily in mental hospitals rather than in the community; only a small percentage of psychiatrists (8%) and psychologists (1%) work exclusively outside government facilities. The authors of the WHO report recommend an investment in “infrastructure and equipment for mental health facilities” (p. 22).
As with Hofstede’s dimensions, Turkey is positioned between Vietnam and the United States in its view of seeking help for mental illness, but it is aligned more closely with Vietnam than with the United States. In Turkey, as in Vietnam, there is a significant stigma associated with seeking help for emotional problems, and these problems not infrequently manifest themselves as somatic disorders, with visits made to medical professionals and indigenous healers rather than to psychotherapists. Similar to Vietnam, family and friendship networks are turned to in times of emotional distress, and for Muslims, illness is perceived to be a test that has been sent from Allah and is something to be endured (see Cinarbas, Owen, & Ciftci, 2009, for a comprehensive discussion of these issues). The services that do exist are underutilized (Cinarbas et al., 2009), suggesting that seeking mental health services may carry with it a degree of stigma.
In comparison with Vietnam, significantly more research on the mental health of university students has been done in Turkey (Erkan, Özbay, Cihangir-Cankaya, & Terzi, 2012). In one of the largest studies reported from Turkey involving almost 6,000 students from 11 universities, Erkan et al. showed that positive attitudes toward and experience with psychological services as well as being female were among the strongest predictors of willingness to seek psychological help.
Only a few articles mention anything about the physical environment of counseling in Turkey; in this regard, Karakücük (2010) suggested that the physical environment plays an important role in such services and identifies some of the features that should be present in the counseling office. These features include a private interview office with calming colors (not a diversity of colors), with sufficient comfortable furniture, and with similar chairs for the counselor and client, or what Sommer (1974) and Chaikin, Derlega, and Miller (1976) described favorably as a soft office. Also mentioned was the importance of lighting, noise control, and ventilation.
In the United States, offering counseling services for college students is widespread. The 2010 National Survey of Counseling Center Directors (Gallagher, 2010) reveals that there are 2.75 million students eligible for counseling in the 320 institutions in the survey. Of the enrolled students, 10.8% sought counseling in the year prior to the survey; the majority of clients (65%) are women. Fifty-six percent of the institutions provide on-campus psychiatric services. Students attending college in the United States are presenting with increasingly severe mental health issues (S.A. Benton, Robertson, Tseng, Newton, & Benton, 2003; Gallagher, Zhang, & Taylor, 2003; Guthman, Iocin, & Konstas, 2010; Mowbray et al., 2006), but research suggests that the stigma associated with mental illness may inhibit the use of mental health services among some college students (e.g., Eisenberg, Downs, Golberstein, & Zivin, 2009; Megivern, Pellerito, & Mowbray, 2003). Thus, some degree of stigma associated with using mental health services is common in all three countries.
In addition to the ubiquity of counseling services for students in the United States, a different situation from that of Vietnam or Turkey, there is considerable research describing what features of the counseling office are judged desirable. To indicate just a few of these, favorable effects have been found with muted lighting (Miwa & Hanyu, 2006), and a “soft” room, including a padded armchair and decorations (Chaikin et al., 1976). Furthermore, the display of credentials has been shown to reflect favorably on the therapist (Devlin et al., 2009).
Hypotheses and Rationale
The United States, Turkey, and Vietnam differ substantially in the prevalence of mental health services for students, the degree to which mental health services are endorsed, and the form of the built environment. Given these differences, how might the evaluations of the 30 psychotherapists’ offices and the judgments about the therapists linked to the offices vary? If the cross-cultural variability holds for responses to these interior spaces, then
participants from the three countries would differ in their evaluation of the quality of care and comfort communicated by the psychotherapy offices, with higher comfort and quality of care ratings from Vietnamese and Turkish participants than from U.S. participants;
responses by participants in each country would yield different models of the degree to which the properties of the offices predicted the quality of care and comfort in the offices; and
properties of the offices that participants judge as influencing their evaluations would differ across participants from Vietnam, Turkey, and the United States.
Given the degree of decoration and softness in many of the offices, which is likely to be less common in health-care–related environments in Vietnam and Turkey than in the United States, students from Vietnam and Turkey would be likely to rate comfort and quality of care higher than would their U.S. counterparts. Furthermore, differences in exposure to psychotherapy might lead Turkish and Vietnamese participants, with less familiarity, to consistently rate the offices high on quality of care and comfort. U.S. participants, with more familiarity, might show more variability in these judgments. In Vietnam and Turkey, people are more likely to share their emotional distress with family and friends than with a therapist (Wallace, 1997). As a result, their preconception of psychotherapists’ offices is less likely to come from direct personal experience, and, especially in the case of Vietnam, with government control of much of what is available in the media (e.g., at various times, Facebook has been blocked in Vietnam), it is unlikely that films and television programs involving therapists (e.g., HBO’s In Treatment or such movies as Analyze This and Analyze That) have been available. At the same time in Vietnam, there is an increasing familiarity with Western design that is evidenced in the built environment (e.g., high-rise design and Western chain stores in retail developments). In the United States, the media depiction of psychotherapists and their offices is commonplace.
Despite this evidence pointing away from the consensus assumption, other research suggests the possibility of commonalities in responses across the cultures, as noted earlier in this article. Research suggests a strong possibility of commonalities in responses to places. A meta-analysis of more than 19,000 people evaluating more than 3,200 environments found a good deal of similarity between responses of students and adults, men and women, and across cultural groups (Stamps, 1999). Such consensus might apply to assessments of psychotherapists’ offices. A study of a diverse sample of participants who had experienced therapy found that evaluations of therapists and ratings of the importance of characteristics of their offices did not differ with age, education, gender, or income of the respondent (Backhaus, 2008). Similarly, a set of studies of student responses to color photos of 30 psychotherapists’ offices found similarities between responses of those who had experienced therapy and those who had not, men and women, different levels in school, and different size and location of the school. The similarities emerged on ratings of the quality of care and comfort expected in each office, in how qualified, bold, or friendly the therapist in the office would be, in the choice of a therapist based on the office, and in the relative importance of various characteristics of the offices in affecting their judgments (Nasar & Devlin, 2011). A related study (Devlin & Nasar, 2012) found that responses from therapists were similar to those of the students for all of the items tested (quality of care, comfort expected, how qualified, bold, or friendly the therapist in the office would be), and in the relative importance of various characteristics of the offices in affecting their judgments.
In light of the differences between the three cultures described in this article, if commonalities emerge in response to the offices, that pattern may suggest that characteristics of the offices had a larger impact on responses than did the characteristics of the different cultural groups. If the consensus assumption holds, then
participants in the three countries would not differ in their ratings of the expected quality of care and comfort in the psychotherapy offices;
responses by participants in each country would yield similar models of the degree to which the properties of the offices predicted the quality of care and comfort in the offices; and
properties of the offices that participants judge as influencing their evaluations would be similar for participants from each country.
The present study sought to determine the degree to which participants from the three countries share patterns of responses to the offices. Given the growing need for psychotherapists and psychotherapy offices in Turkey and Vietnam and the influence of Western ideas that is likely to continue, the evaluation of the décor of offices of psychotherapists provides a starting point to understand the preferences of young Vietnamese and Turkish students of these Western offices.
Method
Participants
The sample had 192 participants (110 women, 81 men, 1 NA; age, M = 22.5, SD = 4.9 years; 165 undergraduates, 25 graduate students, 2 NA) from the United States, Turkey, and Vietnam. Most of them were Caucasian (76.0%, n = 146) and more than one third of them (35.9%, n = 69) reported that they had visited a therapist at least once (median number of visits, 6). Of those who reported seeing a therapist, 28.8% (n = 20) reported 1 to 2 visits and 47.8% (n = 33) reported 3 to 20 visits.
Of the 70 Turkish participants, we dropped five who did not make all of the quality of care and comfort ratings, leaving a sample of 65 (37 women, 28 men; age, M = 21.4, SD = 4.6 years; 64 undergraduates, of whom 43 were 1st-year students, 19 were sophomores, and 2 were upper level students). All were Caucasian, and few of them reported that they had visited a therapist at least once (13.8%, n = 9; median number of visits, 2). Of those who reported seeing a therapist, 66.7% (n = 6) reported 1 to 2 visits and 33.3% (n = 3) reported 3 to 20 visits.
Of the 29 Vietnamese participants, we dropped three who did not respond to all of the comfort or quality of care questions, leaving a sample of 26 (23 women, 3 men; age, M = 19.5, SD = 1.3 years; all undergraduates, 18 1st-year students). All but one participant (who reported a mixed ethnocultural grouping) reported that they were Asian, and few of them reported that they had visited a therapist at least once (23.1%, n = 6; median number of visits, 3). Of those who reported seeing a therapist, 33.3% (n = 2) reported 1 to 2 visits and 66.7% (n = 4) reported 3 to 20 visits.
Of the earlier 104 U.S. participants, we dropped three who did not make all of the quality of care or comfort ratings, leaving a sample of 101 (50 women, 50 men, 1 NA, age, M = 24.1, SD = 5.2; 75 undergraduates, 24 graduate students, 2 NA). Most of them were Caucasian (79.2%, n = 80), and most of them reported that they had visited a therapist at least once (53.8%, n = 56; median number of visits, 10; no response for 1). Of those who reported seeing a therapist and reported the number of visits, 20.7% (n = 11) reported 1 to 2 visits, and 42.9% (n = 24) reported 3 to 20 visits.
Stimuli
The study used digital color photos of 30 psychotherapists’ offices in Manhattan. Each of the photographs taken by the photographer Saul Robbins shows the view of the office with the therapist’s chair as the focus. The view, perspective, and distance in the photograph were controlled across offices (see Figure 1). The stimuli result from opportunity sampling drawn in four ways. The photographer sought referrals from people he knew or met, made cold calls to referrals from friends and other therapists, had a web site with a link inviting people to contact him, and posted a message to a LISTSERV from New York University. More than 95% of the therapists he contacted agreed to the photograph. The offices were all in Manhattan with a majority from the Upper West and Upper East Side, and some from Union Square, Midtown, Columbus Circle, and Gramercy Park. The psychotherapists whose offices were photographed reported degrees and licenses in a range of disciplines including psychology (MA, PsyD, PhD, ABSNP, ABPP), social work (MSW, MCSW, CSW, LCSW, BCD), medicine (MD), nursing (RN, MSN), and education (MEd). The largest number reported having a PhD in psychology (8) or licensed clinical social work (8).
The 30 photographs of the psychotherapists’ offices used in the studies, arranged from highest (upper left) to lowest (lower right) reflecting the means across the three student samples on the composite of quality of care and comfort.
To reduce order effects, each participant was assigned at random to one of four different orders of the offices. Neither the photographer nor investigators knew the kind of clients served, their presenting problems, or the theoretical approach of the therapist. The stimuli combined some experimental control (photos taken from the viewpoint of the therapist’s chair) with offices actually used for therapy, as opposed to simulations. The quality of care and comfort in the environment data for U.S. students were part of a larger data set on judgments of psychotherapists’ offices used in analyses in previous research (see Devlin & Nasar, 2012; Nasar & Devlin, 2011).
Office Environmental Ratings
The predictor variables were the perceived physical characteristics of the offices. To assess those characteristics, 12 judges rated physical characteristics of each office on seven 7-point scales: simple–complex, spacious–cramped, orderly–disorderly, neat–messy, modern style–traditional style, hard office–soft office, and impersonal–personalized. The judges were graduate students in city and regional planning (see Nasar & Devlin, 2011, for details). Each scale had a high interobserver reliability (α > .77). A maximum likelihood factor analysis with varimax rotation found a two-component solution that explained most of the variance (57.9%). We reversed and labeled the first component “orderly.” Four variables had high loadings on it: disorderly, messy, cramped, and complex. We labeled the second component “soft/personalized.” Two variables had high loadings on it: personalized and soft office. The relation between personalized and soft office may result from therapist choice, the character of personalization features, or a mix of the two. Therapists who personalized their offices with mementos may have also had softer offices. Some personalizing features, such as plants, sculptures, a blanket, or article of clothing, may have increased personalization. For predictor variables in the subsequent analyses, we combined the variables with high loadings on each component into two summary variables (orderly and soft/personalized), which were not correlated with one another at a statistically significant level. The offices varied on orderly from 2.40 to 6.44 (M = 4.62, SD = 0.96) and on soft/personalized from 2.38 to 5.76 (M = 4.24, SD = 0.96).
Procedure
All students responded via four URL’s representing four different orders of the office. U.S. and Vietnamese students responded to an English version of the survey. Turkish respondents responded to a version translated into Turkish.
In the Northeast United States, we recruited the undergraduate sample from an institution’s research bulletin board; in the Midwest United States, we recruited graduate students through an e-mail solicitation in a city and regional planning course.
In Vietnam, we recruited participants by asking students enrolled in English classes at a Vietnamese university in Hanoi to take part. As a chance to practice their English, their instructor gave them the option of taking the study online or doing another assignment for class. The study was explained and the URLs were distributed in class. In addition, a small number of participants were recruited through a snowball technique, in which American students studying in Hanoi asked Vietnamese students they had met to participate. The American students e-mailed the URLs to these Vietnamese acquaintances.
In Turkey, we recruited students from an undergraduate course in city and regional planning at a large university. Students who agreed to participate were invited to a departmental computer laboratory at one of seven dates and times. Each student was seated at a computer, which had one of the four URLs activated.
Each URL had the same introductory material and informed consent. The study was described as one that seeks to understand people’s perceptions of therapists’ offices. You will be asked to view and rate 30 photographs of therapists’ offices and answer some questions about your background. You will see pictures of 30 real offices and be asked to give your opinion about the personal characteristics of the individual whose office you viewed. Please respond to the office and not the quality of the photographs. There are no right or wrong answers. We’re interested only in your honest opinions.
The text continued “The pictures show real offices of psychotherapists with the therapist’s chair as the focal point. The person is a psychotherapist; and you are visiting this person for advice about an emotional problem.” They were instructed to scan down and answer questions after looking at each office. The instructions stated, “From the photo of the office, rate what you would expect in terms of the quality of care delivered in this environment and how comfortable you would feel in it.” Participants then rated each office on two items, “quality of care expected” and “feeling of comfort expected,” on 7-point scales from very poor to very good. These two items had emerged as important in judgments of care (Devlin, 2008).
After the questions about the 30 offices, the survey had an open-ended question asking for the characteristics of the offices that stood out and influenced the ratings, followed by a list of 23 factors (such as size, plants, and neatness) to rate on a 5-point scale for the importance of each in affecting their judgments. The survey ended with questions about the participant’s background, experience with therapy, and a debriefing statement.
Results
For the 192 participants from the three countries, we calculated the mean scores separately for perceived quality of care and comfort for each office, the items rated by participants for each of the 30 offices. To see if the groups responded similarly to the offices, we compared responses across the three countries in three ways. First, we examined the correlations of quality of care and comfort ratings between the three countries. Second, through multiple regression analyses, we sought to see if similar attributes related to the composite evaluation (of quality of care and comfort) for respondents in each country. Third, we examined the correlations of importance scores given to each of 23 attributes by participants from each country. To confirm the consensus assumption, we expected to find similarities in responses across the groups, and all three sets of analyses revealed such similarities.
The Pearson correlations of the means from each country were high (see Table 1) and explained between 49% and 88% of the variance. They were also high for gender (men and women), whether the participant had prior experience with therapy, and year in school (1st or 2nd year vs. upper level or graduate student), each explaining more than 82% of the variance, with all r values exceeding .90 and associated p values < .001.
Pearson Correlations Between Ratings by Participants From Each Country (Offices, N = 30).
The average of each combined quality of care and comfort rating was used for the composite evaluation.
To examine the relationship between attributes of the offices and their evaluative appraisals, we used the mean attribute score (for soft/personalized and for orderly) for each office as predictor variables. For the criterion variable, the high correlation between comfort and quality of care suggested that they could be combined into a composite evaluation scale. Thus, to test the degree to which people from different countries responded to attributes of the offices in similar ways, we had to use office (each with attribute scores and a composite evaluation score) as the unit of analysis. The composite evaluation score varied from 2.52 through 5.52 for U.S. participants (M = 4.44, SD = 0.66), from 2.16 to 5.01 for Turkish participants (M = 4.16, SD = 0.61), and from 3.37 to 5.69 for Vietnamese participants (M = 4.74, SD = 0.62).
The multiple regressions for participants from each country separately yielded similar results on the size and the direction of effects of softness/personalization and orderly on the composite evaluation score (see Table 2). R2 ranged from .30 to .52 and adjusted R2 ranged from .25 to .49. For Vietnamese participants, the effects of orderly achieved only marginal significance. We did not find any interactive effect of soft/personalized and orderly on the composite evaluation score.
Regressions of Soft/Personalized and Orderly Onto Mean Composites of Comfort and Quality of Care for Participants From Each Country (Offices, N = 30).
To test for the interaction of soft/personalized and orderly, we first centered each variable by subtracting its mean from its score for each office; centering the variables reduces multicollinearity. Then, we created the interaction term by multiplying the two centered variables by one another. The new regressions for each country used the two centered variables and the centered interaction variable as predictor variables, and the composite of comfort and quality of care as the criterion variable. For each country, the interaction term was not statistically significant. As before, for the U.S. and Turkish respondents, the centered soft/personalized and orderly variables had a statistically significant effect; for Vietnam, the centered soft/personalized had a statistically significant effect, and the centered orderly had a marginally significant effect, but in each case, the centered interaction term was not marginally or statistically significant.
In addition, we tested the interaction of Country × Orderly and Country × Soft/personalized in general linear models, and the analysis confirmed statistically significant main effects of orderly and soft/personalized on the composite evaluation score, but found no moderating effect of country in the Country × Orderly or Country × Soft/personalized interaction.
Next, we examined the correlation between the rated importance in influencing respondents’ judgments of each of 23 attributes by participants in each country. The analyses confirmed similarities across participants from each country. The importance scores had high Pearson correlations between countries (Turkey–United States, r = .81, p < .001; Turkey–Vietnam, r = .49, p < .01; Vietnam–United States, r = .54, p < .01). High Pearson correlations also emerged for gender (r = .96, p < .001), experience with a therapist (r = .93, p < .001), and year in school (r = .90, p < .001). Participants from each country differed in the rated importance of some properties, revealed in ANOVA tests of each property’s importance ratings across countries. In particular, the groups differed in the rated importance of neatness, orderliness, simplicity, painting, carpet, chair cover, ottoman, chair mobility, and color (p < .002, for the Bonferroni adjustment), yet the differences were consistent. Turkish participants had the highest importance ratings for each property; and Vietnamese participants had the lowest importance ratings for all but two properties (ottoman and chair mobility). For those two exceptions, the U.S. participants had the lowest importance scores.
Finally, the overall pattern of importance scores confirmed the importance of softness/personalization and to a lesser extent orderly (see Table 3). For this analysis, we reduced the samples from the United States and Turkey to the same size as the sample from Vietnam, by randomly selecting 29 observations from the two countries. Participants rated chair comfort as highest in importance, and neatness and orderliness among the most important attributes in influencing their judgments. The difference in the rated importance of the attributes was statistically significant, F(22, 1892) = 13.14, p < .001. Post hoc tests with Bonferroni adjustments revealed that participants judged chair comfort more important at a statistically significant level than they did for all of the other attributes except for color, style, windows, neatness, orderliness, and space. Participants judged color and style as more important at a statistically significant level than they did for 12 other attributes; windows as significantly more important than eight other attributes; neatness, orderliness, and space as significantly more important than seven other attributes; books and paintings/photos as significantly more important than two other attributes; and simplicity, carpet, and personal items as significantly more important than one attribute (ps < .05). The remaining attributes did not differ from one another.
Rated Importance of Office Attributes.
Note. A 5-point scale (1 = most important, 5 = least important) was used for rating.
Discussion and Conclusion
The results confirm the consensus assumption. They indicate similarities across three cultures in assessments of the offices of psychotherapists, reflecting the importance of softness and personalization and orderliness in predicting the composite evaluation of comfort and quality of care. In addition, for each country, soft/personalized and orderly did not have an interactive effect on the composite evaluation. This outcome means that in each country neither attribute moderated the effect of the other on the composite evaluation. These consistencies parallel findings of cross-cultural agreements on interpersonal perception and personality judgments (Albright et al., 1997), showing that such agreement also occurs cross-culturally for physical cues from the office as they relate to characteristics of the occupant.
Although the countries had some differences in importance ratings, these ratings were consistent (highly correlated) across the three groups. The differences resulted from consistently higher scores from one group and consistently lower scores from another; they did not affect the relative rated importance of the physical properties. For that reason, the ratings suggest differences in the manner of responding (or set) rather than in the evaluation of the importance of the properties themselves.
The cross-cultural stability of affiliation and intimacy in human relations (Adamopoulos & Bontempo, 1986) suggests that the soft/personalized characteristics of the offices responded to similarly across cultures may be an important evaluative dimension. Agreeableness and conscientiousness may also impact the credibility of the therapist and affect whether a patient remains in therapy (Amira & Abramowitz, 1979; Strong, 1987; Sue & Zane, 1987). However, the findings here reflect responses from students, who may have certain commonalities, in spite of their culture, due to globalization across cultures from school and university socialization. Furthermore, the findings reflect responses to offices in the United States (or more narrowly, an opportunity sample of offices in a few areas in Manhattan). Thus, we suggest that future studies use more sociodemographically diverse samples of participants from different cultures to evaluate an international sample of offices. Furthermore, although using offices as a unit of analysis revealed similar responses across the groups in each culture, we did not test individual responses, which could be addressed in future research.
Despite that caveat, the consistency of responses to orderliness and softness/personalization across samples leads to intriguing questions concerning the mechanisms underlying this pattern. With the increasing influence of neuroscience, even within social psychology (e.g., Ochsner & Lieberman, 2001), future research could examine the relationship between evaluations of the physical environment and neuroscience across diverse cultures and stimuli. Given that humans are limited-information–processing animals whose working memory is time limited (e.g., Baddeley, 1986), we may prefer displays that, because of their composition and order, are easier to visually scan. Particular kinds of spatial arrays, varying in their degree of composition and orderliness, may be responded to differentially and predictably in terms of brain function. In Kaplan’s (1987) environmental preference model, coherence features prominently as one of the structural predictors of preference; coherence facilitates understanding in an immediate fashion. In describing the effect of coherence, Kaplan talks about the degree to which a scene hangs together; scenes with coherence have “repeating elements and unifying textures that contribute to a ‘good gestalt’” (1987, p. 10). Kaplan’s model emerges out of an emphasis on evolution; in that regard, it would not be surprising that characteristics, such as orderliness, that reflect a kind of coherence, are responded to similarly across cultures. Research in neuroscience further supported by the new government initiative on mapping the activity in the brain (Markoff, 2013) will undoubtedly tell us more about the effect of environmental stimuli on brain function. Such research may discover whether there are perceptual and neural equivalents of the preference for orderliness that emerged in the present study.
The degree of softness/personalization may relate to the human need for interpersonal intimacy and agreeableness. For the cognition of emotion, before they can experience it, humans may need both knowledge (the declarative information) and appraisal (how the situation applies to us personally; Lazarus, 1991). In the context of the therapy office, a personalized setting may suggest to the viewer that the occupant is experienced in acknowledging the importance of personal relationships.
The predictors of the composite evaluation were highly correlated across cultures but there was variability in the range of the composite evaluation scores. These findings suggest that the conceptual relationships between the variables are stable across cultures, that is, personalization/softness and orderliness bear the same relationship with perceived judgments of care and comfort in the environment across the three cultures. At the same time, the fact that the absolute value of the composite ratings differed suggests a different baseline or set point. Recall that research on Vietnam suggests that the country has less infrastructure devoted to mental health facilities than the United States or Turkey. For the composite evaluation of care and comfort, the set point for the Vietnamese respondents was about a point higher than for either the U.S. or Turkish respondents. This higher set point agrees with the idea that the Vietnamese participants may have been more impressed with the décor of the offices than were the U.S. and Turkish respondents, although there may be other explanations for this difference.
Although the results of this research lend some preliminary support to the theoretical notion of the consensus assumption for aspects of physical environments, such as their orderliness, there are practical recommendations for therapists as well if the findings hold. Therapists might be advised to select a chair for themselves that communicates comfort, with an ample seat and soft cushioning. Although not the focus of study in this research, the chair for the client is important as well. In Karakücük’s (2010) research on school guidance services in Turkey, for example, having similar chairs for the professional and the client was recommended. The suggestion to select a comfortable chair may seem obvious, given the focus on the therapist’s chair in the photographs. What might not have been expected is the role of neatness in people’s judgments. Neatness may function to communicate the therapist’s ability to organize tasks (and one might speculate to help bring order to the patient’s life); in fact, order was another highly rated indicator. Color, style, space, and windows also affected respondents’ judgments. A good design may involve a compatible mix of such elements that creates a pleasant and professional setting. Taken together, one could imagine guidelines for a therapist’s office that involved windows, the use of color for decoration (as culturally appropriate), sufficient space to provide a choice of seating for patients, and presumably enough room to avoid bumping into furniture. We found it surprising that nature (here in the form of plants) did not play a major role in people’s judgments, particularly as nature has been shown to have a significant role in restoring attention and improving health outcomes (e.g., Berman, Jonides, & Kaplan, 2008; Ulrich, 1984). This outcome is likely related to the limited presence of plants in the photographs; fewer than five of the photographs had plants. Given the important role of nature in health and restoration (Berman et al., 2008; Ulrich, 1984), future research could consider effects of nature or views of nature in the psychotherapist’s office as well as the degree to which the highly rated soft/personalized therapists’ offices might be judged to be more restorative (in terms of attention) and supportive (Ulrich, 1991) than offices without those characteristics.
Limitations
The results need to be understood within the parameters of the data. The samples were small, particularly the sample of Vietnamese students, but the unit of analysis was 30 offices. Although the Vietnamese sample is small, the results can be of importance as very little research is published on Vietnamese students, and none that we could find related to judgments of psychotherapeutic environments.
In addition, the study comprised primarily women, but research indicates that women are more likely to seek counseling than are men (Erkan et al., 2012). A further limitation is that the data were not collected at the same points in time; thus, history (Campbell & Stanley, 1963) may be a threat to the internal validity of the study. The Vietnamese and Turkish student data were collected in 2011 and the U.S. data from 2008 to 2010. History would be a problem if we tested for and found difference between the groups. It is less of a threat in tests finding similarities across the groups, as was the case here.
We may have unintentionally defined what we measured (the properties of the offices and the evaluative responses) from a Western or etic perspective and thus missed the emic or within-culture knowledge. Moreover, although 30 offices were rated, the photos were taken for nonresearch purposes (yet keeping the focus on the therapist’s chair consistent across photographs), and the offices represented variability in the United States, and even more narrowly for Manhattan. These aspects limit the generalizability of the results and the degree to which the influence of culture on such judgments can be tested. Even in the absence of a dispersion of responses, as was the case in our results, an emic approach to the research questions posed here is important to balance what can be learned from different perspectives. In that regard, an avenue for future research would emphasize the emic approach, starting with a random sample of psychotherapists’ offices from the three different countries. Photos of such offices might be obtained from psychotherapists who belong to national mental health organizations and practice in major urban areas. Research could also try to learn whether ratings of comfort and quality of care make sense in each country, and if not, what variables do. Qualitative techniques, such as cognitive interviews, might find appraisals relevant to each culture.
We do not know how impressions of the quality of care and comfort in these offices might have changed over the course of therapy, which is also an important avenue for future research. At the same time, some research suggests that the first session is important in whether an individual returns for additional sessions (Alcázar Olán, Deffenbacher, Guzmán, Sharma, & De La Chaussée Acuña, 2010; Sexton, Littauer, Sexton, & Tømmerås, 2005). Given the role of the physical setting as part of a healing environment (Frank & Frank, 2004), the impression made by the physical setting in the first encounter should not be ignored.
Future research can move beyond the physical characteristics of softness/personalization and orderliness to consider other kinds of elements that may affect responses in similar and different ways in different ethnocultural groups, thereby further testing the consensus assumption as it relates to characteristics of the physical environment. To better ascertain cause, such research could do controlled manipulation of those elements in offices and, for broader generality, do those tests in a more diverse set of offices. Participants did not experience the offices in person. Although responses to the photos like those used in this study generalize well to on-site responses (Roth, 2006; Stamps, 1993; Ulrich et al., 1991), research could test such manipulations using on-site evaluations cross-culturally and do so for different kinds of professional offices or waiting rooms (such as those of architects, doctors, lawyers, and professors).
Conclusion
Across three quite different cultures, the role of softness/personalization and orderliness emerged as similarly valued in making judgments about the quality of care expected and degree of comfort likely to be experienced in 30 psychotherapy offices. Particularly in Turkey and Vietnam, the family is still more likely to be a source of support for those needing assistance with mental health issues than is a trained psychotherapist. At the same time, if both the acceptance of the idea of psychotherapy and its availability increase in these countries, it will be important to think about the kinds of physical settings that support such intervention. The fact that 23.1% of the Vietnamese sample and 13.8% of the Turkish sample reported having seen a therapist at least once suggests that even now there is some familiarity with such services. As a starting point, the work here suggests that offices with orderliness and softness/personalization should be considered in the design of those settings. In extending this research, we can develop a better understanding of how to create built environments that are compatible with the meanings, ideas, and values of the occupants. This kind of understanding may be particularly important in clinical settings, where there is often a high level of emotional distress.
Footnotes
Acknowledgements
We thank Saul Robbins for letting us use his photographs and Meghan Marchie for help with data collection in Hanoi.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article