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Received: 1 September 2020    Revised: 21 November 2020    Accepted: 23 November 2020

DOI: 10.1002/capr.12376

SPECIAL SECTION ON RESEARCH MIXED METHODS

What’s in a therapy room?—A mixed-methods study exploring

clients’ and therapists’ views and experiences of the physical
environment of the therapy room

T. Sinclair

Correspondence
Email: tssinclair2@gmail.com Abstract
Aim and objectives: To explore the importance of the physical space of therapy
rooms (used for counselling/psychotherapy) to clients and therapists. To identify
which aspects of therapy rooms are most important to clients and therapists and
how these aspects contribute to an environment that is conducive or hindering to
the therapy process.
Method: This was a mixed-methods study, using a concurrent triangulation de-
sign. Data were gathered using an online survey and semi-structured interviews.
Quantitative and qualitative data were analysed using statistical analysis and thematic
analysis, respectively. Participants were twenty-four clients who had experienced
counselling or psychotherapy and twenty-one qualified therapists (psychologists,
counsellors and psychotherapists).
Findings: From the survey data, comfortable seating and room temperature, sound-
proofing, no interruptions and accessibility of the room were identified as most
important to clients and therapists. Participants reported that feeling physically
comfortable and safe in a room enabled a greater engagement with the therapeu-
tic process. Rooms with a ‘clinical’ appearance were described as unhelpful. From
the interview data, themes identified were as follows: ‘comfort’, ‘the appearance and
meaning of the room’ and ‘the room as a workspace’.
Conclusions: The physical environment of the therapy room can play an important
role in clients feeling comfortable and able to engage. It is important to consider the
appropriateness of rooms for particular client groups/issues and consult with clients
and therapists about therapy rooms. Further research is needed into the interaction
between clients’ presenting issues and the room and the effect of cultural differ-
ences upon the experience of therapy rooms.

KEYWORDS

client, counselling, psychotherapy and counselling approaches, experiences, therapist,

therapy environment, therapy room

© 2020 British Association for Counselling and Psychotherapy

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wileyonlinelibrary.com/journal/capr Couns Psychother Res. 2021;21:118–129.
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1 |  I NTRO D U C TI O N A N D R ATI O N A LE
Counselling and psychotherapy in the UK that is not done online
usually takes place in a room chosen or designated by the counsel-
lor/therapist or service provider. There has been a lack of research
into what impact (if any) the physical environment of a therapy room
has on the client, therapist, process and outcome of the therapy.
Pressly and Heesacker (2001) argue that therapists and therapy pro-
viders often make fundamental attribution errors regarding clients
and neglect the situational context of the therapy room, overlooking
the less obvious influence of different elements of the environment.
There are important questions regarding whether the therapeu-
tic space can influence client motivation, trust in the working alli-
ance, the therapist's ability to work and client outcomes (Pearson
& Wilson, 2012). For the purposes of this paper, the terms ‘talking
therapies’ or ‘therapy’ will be used to encompass all forms of coun-
selling and psychotherapy; the term ‘therapist’ to describe the coun-
sellor, psychotherapist, psychologist or practitioner delivering the
therapy; and the term ‘therapy room’ to denote the room where
therapy takes place.
Increasingly, within services such as increasing access to psy-
chological therapies (IAPT), a variety of different rooms are used for
talking therapies, including GP surgeries and rooms in the commu-
nity. Clients are often not given the opportunity to give feedback
about the rooms they use (McLeod & Machin, 1998). There are also
questions regarding which data gathering methods are appropriate.
McKellar (2015), in assessing the state of research into psychiatric
wards, argues that when measures have been used to gather data
on service user perspectives regarding the environment, quantita-
tive methods have usually been used, which do not accommodate a
wider narrative.
Given the lack of research, how then can therapists and service
providers determine which aspects of the physical environment of
the therapy room are significant factors and ensure that rooms they
use are conducive to therapeutic conversations?
1.1 | Environmental psychology
Within the wider field of environmental psychology, research has
consistently shown that physical settings impact upon the peo-
ple within them (Lei,  2010; Maslow & Mintz,  1956; Ulrich,  1984).
Furthermore, the physical environment can affect the impressions
that people have of individuals inhabiting a particular setting (Devlin
et al., 2009; Maslow & Mintz, 1956).
1.2 | The function of the therapy room
An important question is: What function does the therapy room
serve? Frank and Frank (1993) suggested that the therapy room is a
healing setting and that the healing setting provides two functions
that aid therapy. Firstly, it helps to establish the role of the therapist,
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increasing their ‘prestige’ in the mind of the client and the expecta-
tion of the help that may be received. Secondly, it provides a safe
place where clients can feel safe and secure for the duration of the
session. Feeling safe encompasses both a subjective emotional re-
sponse to an environment, and more tangible aspects, such as not
being overheard or at risk of physical harm.
The therapy room can also be seen as part of the ‘frame’ of ther-
apy (Gray, 2013), the important containing framework, within which
therapy is conducted. Waldburg (2012) further suggested that the
therapy room acts as a ‘symbolic container’ for the client's story.
Backhaus (2008), in a large mixed-methods study of 226 clients
and therapists in the United States, found that the physical environ-
ment of therapy rooms can give rise to feelings of safety, comfort
and relaxation and that client retention was significantly associated
with a ‘welcoming environment’ (as perceived by clients).
Pressly and Heesacker (2001), in their review of the literature
regarding the physical space of therapy rooms, outlined the need
for an environment that is facilitative of therapy processes such as
developing rapport, self-disclosure and exploration. They also focus
their overview of the literature on specific physical elements that
either detract from or enhance the therapy process.
Very little has been written about the overall function, meaning
and experience of the therapy room from the client's point of view.
1.2.1 | Reflexivity
My interest in this area initially developed as a result of a number of
negative and positive experiences of therapy rooms, both as a client
and as a therapist. Talking about these experiences with colleagues
led me to realise that there were many ways in which a therapy room
could be perceived as either hindering or helping the therapeutic
process, relationship or outcome. It also became apparent that there
was a lack of voice given to client and therapist users of rooms, within
the small amount of research that there was. I therefore sought to
design a study that would give voice to client and therapist users
of rooms and explore the role and impact of rooms used for talking
therapies in the UK.
1.2.2 | Overview of some of the existing literature
relating to aspects of therapy rooms
The appearance and design of the room
McLeod and Machin (1998) argue that the layout of the room con-
veys expectations about what will take place within a room. Rooms
used solely for the purpose of therapy could conceivably convey dif-
ferent expectations, compared to dual-use rooms, such as those in
GP surgeries, where examination beds and medical equipment may
also be in the room.
Within the NHS, therapy rooms in primary and secondary care
often reflect a medical model, with psychiatric wards particularly
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120       SINCLAIR
reflecting a medicalised environment (McKellar, 2015). This is inter-
esting to consider, in terms of the debate around the medicalisation
of distress and how clients might come to understand and frame
their own issues.
Limitations of many studies relating to therapy rooms are that
much of this research has involved psychology students as op-
posed to actual clients and therapists (Chaikin et  al.,  1976; Miwa
& Hanyu,  2006; Nasar & Devlin,  2011). Furthermore, often pho-
tographs of therapy rooms are used in the place of actual therapy
rooms. It seems unlikely that the overall experience of a therapy
room, including smell and noise, could be gained through looking at
a photograph.
Nasar and Devlin (2011), in their study of psychology students in
the United States observing photographs of therapy rooms, found
that ‘soft’ and personalised rooms with soft furniture, soft lighting
and pictures on the wall were preferred. Similarly, Backhaus (2008),
in her study using actual clients and therapists, found that clients
preferred rooms with a more ‘homely’ feel.
The importance of the wider organisation or culture that the
therapy is provided within was noted by McLeod and Machin (1998),
who note that many counselling agencies operate within larger
organisational units such as university counselling services or em-
ployee counselling services. This can influence the values or goals
of the service and the physical space of the therapy rooms that are
provided.
Seating
Seating in therapy rooms varies in type and position. Backhaus
(2008), in her mixed-methods study, found that seating was con-
sidered by clients and therapists to be the most important item of
furniture within therapy rooms. The preference was for large, soft
and comfortable seating. Pearson and Wilson (2012), in their survey
of Australian counsellors, found that a choice of seating (different
sizes and types) for clients was considered important. Furthermore,
a significant number of counsellors deemed the physical comfort of
the client to be a necessity.
Interaction distance was outlined as a factor by Pressly and
Heesacker (2001), who noted that although clients can have dif-
ferent preferences, in general, they tend to prefer intermediate
distances during therapy of between 1.2 and 1.5 metres. However,
cultural differences also need to be taken into consideration, as
clients from certain cultures prefer smaller interaction distances
(Remland et al., 1995).
Lighting
In their study involving 80 students being ‘interviewed’ by a counsel-
lor, Miwa and Hanyu (2006) found that dim lighting facilitated self-
disclosure and increased communication. Gifford (1988) also found
that participants performing a letter writing task increased the level
of their self-disclosure when in a room with dim lighting as opposed
to one with bright lighting. Backhaus (2008), in her study of actual
clients and therapists, found that both groups preferred natural or
subdued lighting, with natural light through windows as first choice
and lamps coming second.
Sound and privacy
Confidentiality is a key factor in talking therapies, and poor sound-
proofing can risk breaches of confidentiality. Pressly and Heesacker
(2001) suggest that music or water sounds could be used to pre-
vent therapeutic conversations from being overheard and increase
clients’ feelings of privacy.
Furthermore, Pressly and Heesacker (2001) point out that high
sound levels can have a hindering effect on introspection and con-
versation, both of which are important to therapy.
Accessories
Clients and therapists in Backhaus’ (2008) study reported clocks,
artwork and plants as being the most important accessories in ther-
apy rooms. Therapists working in private therapy settings will often
have more control over the artwork or other accessories on display
in their rooms.
2 | TH E PR E S E NT S T U DY A N D R E S E A RC H
QU E S TI O N S
The present study addressed the gap in the literature by employ-
ing a mixed-methods approach to explore clients’ and therapists’
experiences of the physical environment of the therapy room. In
doing so, it provides important data on which features of the phys-
ical environment are important to clients and therapists within the
UK; this is important to therapy providers and individual thera-
pists, in terms of creating an environment conducive to talking
therapies.
The aim of the proposed mixed-methods study was to inves-
tigate the importance of the physical environment of rooms used
for talking therapies (all types of psychotherapy, counselling and
high-intensity CBT) to clients and therapists. The mixed-methods
design enabled the range of data gathering necessary to achieve
this, both at breadth and at depth. A wide scope of settings and
modalities was included, in order to get a breadth of data that
would incorporate the wide range of ways that talking therapies
are delivered in the UK.
The objectives were to determine which features of the physi-
cal environment of therapy rooms are most important to UK ther-
apists and clients in contributing to a helpful setting and how these
features contribute to creating an environment that is conducive or
hindering to the therapy process. A further objective was to under-
stand more about how clients and therapists experience the physical
environment of the therapy room generally.
There were two strands to the study: an NHS strand that col-
lected data from NHS therapists and a non-NHS strand that col-
lected data from former clients and non-NHS therapists; this is so
that information regarding a variety of different settings could be
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gathered. Current NHS clients were not included for research ethics
reasons. The two strands used the same research questions.
The first research question built on one of Backhaus’ (2008) re-
search questions by asking not just which aspects of therapy rooms
were important to clients and therapists, but also why?
The research questions were as follows:
RQ1: Which aspects of the physical environment of the therapy
room are important to clients and therapists and why?
RQ2: How do clients and therapists experience the physical en-
vironment of therapy rooms?
This study gave equal weight to the quantitative and qualitative
data; however, a thorough discussion of both is not possible within
the constraints of this paper. Therefore, following the methods sec-
tion, a brief overview of the quantitative component will be given,
before an in-depth focus on the qualitative data.
3 |  M E TH O D
3.1 | Study design
The study was a mixed-methods study, using a concurrent triangula-
tion design (Creswell et al., 2003), with quantitative and qualitative
data analysed separately and then combined to form a discussion
addressing the research questions. A mixed-methods approach can
help to build a more complete picture through complementarity
and through combining quantitative and qualitative methods, and
the strengths of each of the respective methods can be drawn on
and weaknesses offset (Bryman,  2006). Other than for comple-
mentarity, a mixed-methods design was also chosen for two further
reasons: firstly, in order to give a wider and triangulated account
(convergence) of the role of the physical environment of therapy
rooms and capture the whole experience of therapy rooms, which
is a complex area; and secondly, to look for any differences (interro-
gation) between the quantitative and qualitative data. Divergence
between different types of data in mixed-methods studies is not, in
itself, a weakness, and curiosity towards the divergence can bring
greater insight and understanding. Brannen and Moss (2012, p. 2)
outline that a mixed-methods study works best when ‘exploit [ing]
the potential to see different things’.
The mixed-methods design also effectively enabled the different
research questions to be addressed. Quantitative data enabled an
identification of which variables (aspects of rooms) therapists and
clients thought were the most important. The qualitative data gave
more context to the way that the individual variables were experi-
enced and allowed a deeper understanding of why room variables
might be rated more importantly by clients or therapists. This is im-
portant, given the wide range of client groups, issues and therapy
settings. Furthermore, the qualitative data also provided data relat-
ing to how the individual variables combined to provide a helpful/
unhelpful setting.
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3.2 | Data collection and mixed-methods
consideration
Quantitative and qualitative data were collected at the same time,
with equal value given to both. The study made use of three data
sets: the quantitative survey data (NHS and non-NHS strand), the
qualitative survey data (NHS and non-NHS strand) and the qualita-
tive interview data (non-NHS strand). These data sets were analysed
separately, before being compared and contrasted with each other
for the purposes of convergence, complementarity and interroga-
tion. The qualitative data from the surveys were not combined with
the qualitative interview data, in recognition that the data were
gathered in different contexts, which will likely have an effect on
the data. The qualitative survey data were collected within a quan-
titative survey, where specific prior questions about features of the
room have been posed to participants, whereas the interview data
were collected within a qualitative framework and coconstructed
(Mann, 2011) with the interviewer.
3.3 | Participants
The participants were recruited using a combination of opportu-
nity, purposive and snowball sampling. In the NHS strand, Health
Research Authority (HRA) approval for the study was obtained and
a local NHS mental health trust agreed to act as a study site for the
research. To recruit NHS therapists to the study, managers of pri-
mary and secondary care services delivering talking therapies were
emailed details about the study and the survey URL and were asked
to distribute these to staff via email. All qualified counsellors, psy-
chotherapists, counselling/clinical psychologists and high-intensity
therapists with at least two years’ experience (to capture a wider
experience of therapy rooms) were invited to take part in the survey
anonymously. Trainees were excluded.
To recruit therapists in the non-NHS strand, posters advertising
the study were emailed to managers of local counselling and psycho-
therapy agencies to be circulated to staff. The inclusion criteria were
the same as for NHS therapists.
To recruit clients, an advert was placed on Facebook. Client par-
ticipants were over 18 years old and had received at least six sessions
of therapy. The exclusion criterion for client participants was that they
were not currently receiving therapy, to avoid interaction with therapy
or distress to clients still within a therapy process. There was no re-
quirement regarding how recently the therapy had been.
3.4 | Survey
Quantitative and qualitative data were gathered from 24 clients and
21 therapist participants, using an online survey.
The first part of the survey comprised Likert scales asking par-
ticipants about their opinion on the importance of aspects of the
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122       SINCLAIR
physical environment of therapy rooms (outlined below). Seven
of the aspects were based on elements in the questionnaires
that Backhaus (2008) used, and the other aspects were drawn
from client responses in the current author's previous research
(Sinclair,  2013), as these were the aspects that clients most fre-
quently mentioned.
Qualitative data were gathered in the second half of the survey
using three open-ended questions:
Thinking about the physical environment of counselling/therapy
rooms you have experienced,
• has anything about the room ever helped with the therapy
process?
• has anything about the room ever hindered the therapy
process?
• what role do you think that the physical environment of the room
plays in the therapy process?
Demographic questions gathered data about the gender and age
of participants and settings experienced. This information was used
to ‘situate’ the data and inform the write-up.
Online Surveys™ was used to administer the questionnaires. The
questionnaires were piloted to check for clarity, layout and technical
issues.
3.5 | Semi-structured interviews
Further qualitative data from two therapists and two clients were
collected through four 45 min semi-structured interviews, con-
ducted via Skype or face to face and recorded by dictaphone. Six
open-ended questions were developed from findings from the
current author's previous research (Sinclair,  2013), and the three
qualitative questions from the survey (see above) were also used.
Questions included the following: Which physical features do you
think are important in therapy rooms? What role (if any) did the room
play in your therapy? What would you like to have been different
about the room? How important do you think the physical environ-
ment of the therapy room is?
3.6 | Ethical considerations
The researcher adhered to the University of Bristol and British
Association for Counselling and Psychotherapy (BACP) ethical
guidelines for conducting research. Health Research Authority
(HRA) approval was obtained for the NHS strand of the study.
An information sheet was supplied to all participants explain-
ing the research, and informed consent was obtained from each
participant.
All data were promptly anonymised and identifying data re-
moved. Participation in the online questionnaires was anonymous.
4 | A N A LY TI C A L S TR ATEG Y
4.1 | Survey data
Quantitative survey data were downloaded from Online Surveys™
into SPSS™ software. The data were analysed for descriptive statis-
tics, and a statistical analysis of differences between room features
and participant group responses was performed.
The qualitative survey data were analysed using Braun and
Clarke’s (2006) six-stage approach to thematic analysis. A deductive
approach to the thematic analysis was chosen (as explained above),
with themes chosen that answered the research questions.
4.2 | Qualitative interview data
Transcription of the interview data was carried out by the re-
searcher shortly after the interviews took place. The transcripts
were coded and analysed using Braun and Clarke's (2006) approach
to thematic analysis. The analysis was done in an inductive way.
5 | S U RV E Y DATA— R E S U LT S A N D
DISCUSSION
5.1 | Demographic data
Thirty-seven participants identified as female, seven identified as
male, and one person identified as neither/preferred not to say.
Client participants ranged in age from 18 to 64, with the majority in
the 25–34 age range. Therapist participants ranged in age from 25 to
64, with the majority in the 45–54 age range. The number of rooms
experienced by therapists ranged from 4 to 51, and the number of
rooms experienced by clients ranged from 1 to 25.
The majority of clients had spent 1–6 months in therapy rooms,
and most therapists had 5–10 years’ experience.
Therapists and clients had experienced a variety of therapy settings.
The most frequently experienced settings for therapists were NHS doc-
tors surgeries (23%) and NHS psychological therapy services (19%). The
most frequently experienced settings for clients were NHS psychological
therapy services (20%) and counsellor's/psychotherapist's house (19%).
Thirteen therapists (62%) also had their own experience as a
client. This amount may seem surprisingly low; however, this may
reflect the fact that not all therapist training courses require train-
ees to have personal therapy, particularly clinical psychology and
high-intensity IAPT courses.
5.2 | Quantitative survey data
The data gathered were Likert-scale responses to 22 questions
on particular aspects of the room from 45 clients and therapists
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(clients n = 24). The Likert scales ranged from 1 (strongly disagree)
to 6 (strongly agree). To examine which aspects of the room were
most important, the percentages of participants who responded
from 4 (slightly agree) to 6 (strongly agree) using the Likert scales
were calculated for each question, related to the individual as-
pects. The aspects were as follows: comfortable seating, com-
fortable room temperature, accessibility of the room, position of
seating, clinical (medical-type) appearance, soundproofing, room
upkeep (decoration and maintenance), soundproofing, moveable
seating, privacy, using the same room, bright lighting, soft light-
ing, artwork, plants/other accessories, colour of walls, artwork,
homely appearance, client control of temperature, client control
of lighting, therapist control of lighting and consistency of room
layout.
There was a significant amount of agreement from clients and
therapists about the importance of many of the room aspects.
One hundred per cent of clients and therapists agreed to some
extent, ranging from slightly agree (4) to strongly agree (6), that
comfortable seating, no interruptions, comfortable room tempera-
ture and accessibility of the room were all important aspects of
therapy rooms.
In terms of the appearance of the room, 98% of participants dis-
agreed that a clinical appearance was important, thereby seeming to
favour a non-clinical appearance. Furthermore, 71% of the partici-
pants disagreed that bright lighting was important, thereby seeming
to favour less-bright lighting.
5.3 | Assessing for significant difference between
room features
In order to check whether there were significant differences in the
participants’ ratings of the 22 individual room aspects, Friedman's
ANOVA test was used. Client ratings of clinical rooms (N  =  24,
mdn = 1.5, mean rank = 1.71) and bright lighting (N = 24, mdn = 3,
mean rank  =  2.58) showed a significant difference in distribution,
compared with other room features (ps > 0.001).
Therapist ratings of clinical rooms (N = 21, mdn = 2, mean = 2.14)
and bright lighting (N = 21, mdn = 2, mean rank = 2.81) also showed
a significant difference in the distribution of ratings, compared with
other room features (ps > 0.001). These findings will be discussed
below.
5.4 | Assessing for significant difference
between therapist and client views of individual
items/features of the room
A Mann–Whiney test of difference was used for each of the 22
questions relating to room aspects, to determine whether there was
any statistically significant difference between therapists’ and cli-
ents’ answers for each question. Therapist control of lighting was
the only aspect to show a statistically significant difference between
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therapist and client answers, with levels of agreement significantly
higher for therapists (N = 21, Mdn = 5) than clients (N = 24, Mdn = 3),
U = 63.5, p = <.001.
5.5 | Discussion of results
The results suggest that a lack of interruptions is the most impor-
tant aspect of therapy rooms, with 100% of clients and therapists
agreeing at a value of 5 (agree) to 6 (strongly agree) on the impor-
tance of this item. Following this, comfortable seating, accessibility
of the room and comfortable room temperature were also seen as
very important, with 100% of clients and therapists in agreement
with a value of 4 (slightly agree) to 6 (strongly agree). These find-
ings may seem unremarkable; however, it is important to remember
that clients and therapists continue to report experiencing interrup-
tions and uncomfortable seating, and many therapy rooms are still
not fully accessible. Although many of the room aspects attracted a
high amount of agreement in terms of their importance, the results
clearly showed that some aspects of the physical environment of the
therapy room were more important to clients and therapists than
others. In terms of less popular room aspects, bright lighting and
rooms with a clinical appearance were significantly less favoured by
both clients and therapists. Many rooms used for talking therapies
within the NHS have a clinical appearance, and the impact and rel-
evance of this for clients and therapists was revealed in the qualita-
tive data analysis below.
In assessing differences between client and therapist views,
there were no statistically significant differences between client
and therapist views for the majority of the 22 room aspects. This
indicates that therapists and clients agreed about the importance
of the majority of room aspects in the survey. Therapists did, how-
ever, show significantly higher levels of agreement than clients,
and therapist control of lighting was important. In understanding
this further, the qualitative survey data showed that many thera-
pists mentioned their dislike for the motion-controlled lighting in
their workplace. Therapists also spend more time than clients in
therapy rooms, so a need to control lighting may be particularly
salient.
5.6 | Qualitative survey data
The qualitative data gathered from the two online surveys (NHS
strand and non-NHS strand) consisted of free text answers to three
open-ended questions:
Thinking about the physical environment of counselling/therapy
rooms that you have experienced,
• Has anything about the room ever helped the therapy process?
• Has anything about the room ever hindered the process?
• What role (if any) do you think that the physical environment of
the room plays in the therapy process?
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124       SINCLAIR
The majority of participants (41 out of 42) answered all three
qualitative questions. The data from the NHS strand and non-NHS
strand were combined and deductively analysed (using the research
questions) for themes, as outlined above. The therapist data from
the NHS and non-NHS strands were combined, as the NHS strand
consisted only of therapist responses; these were merged with the
non-NHS therapist responses, in order to compare clients’ and ther-
apists’ responses. The themes will be briefly discussed with refer-
ence to the research questions.
RQ1—Which features of the room are most important to clients
and therapists?
The features most frequently mentioned by clients in terms of
helping the process were privacy, seating, soundproofing, overall
appearance of the room and accessories (plants, artwork etc.). The
features most frequently mentioned by therapists as helping were
privacy, seating, soundproofing and temperature.
RQ2—How do clients and therapists experience the physical envi-
ronment of the therapy room?
5.7 | The comfort of the room
Comfort and being comfortable within the therapy room were men-
tioned a number of times by clients and therapists across the three
questions, particularly in relation to the role of the room.
5.8 | A safe space
The need for the therapy room to feel like a ‘safe space’ was fre-
quently mentioned by therapists and clients; this was in agreement
with the qualitative findings of Backhaus (2008). Some highlighted
the vital role of a sense of safety, especially when working with cli-
ents with trauma issues or doing imaginal exposure work:
For stressed traumatised people, having a room that
feels safe is paramount; sudden noises or noisy envi-
ronments can stop therapy happening—
Therapist (S6).
5.9 | Facilitating or hindering therapy
A ‘good room’ was described by many as being able to help the ther-
apy process, through a feeling of physical and emotional comfort,
safety and privacy. Furthermore, a ‘good room’ was described as
enabling the therapy process through a lack of distraction.
Many therapists and clients also felt that the room could help
build the client and therapist relationship; one therapist described
it in this way:
It adds to the rapport building and sense of the ther-
apy being a safe space. If a client feels safe and held
within the environment, the therapeutic relationship
can be stronger—
Therapist (S10).
5.10 | ‘Clinical’ rooms
Many clients and therapists referred to ‘clinical’ rooms (rooms with a
medical appearance) as being unhelpful and hindering, and this was a
prominent theme within the data. The possibility for rooms with a medical
appearance to make clients feel they were attending a medical appoint-
ment or convey a medical model of understanding distress was noted:
(The NHS trust) treats our clinical space as if it is part
of a hospital ward -cold bright lighting, no comfort-
able chairs or soft furnishings, little or no artwork on
the walls. I believe this gives the message that what
is wrong with the client is a biological/medical prob-
lem and so should be treated with medication and not
talking therapy—
Therapist (S9).
One respondent described how a room with a medical appearance
had been so unhelpful that it played a large part in them not returning
to therapy:
I had an introductory session in a medical centre. It
was a brightly lit cubicle with a bed, a spotlight, and
two uncomfortable chairs. As a result of past medical
procedures, I always feel anxious in this type of envi-
ronment. I did not continue with the therapy; this was
a big part of the reason why—
Client (S15).
5.11 | Inappropriate rooms
Some client and therapist respondents described experiences when
a therapy room had been experienced as inappropriate or hindering.
One client described her experience:
One therapy session took place in a kitchen within the
building, as that was the only room available, but as
the therapy was centred on an eating disorder it was
a completely unacceptable and inappropriate setting
for the session to take place in and I shouldn’t have
been put in that position—
Client (S19).
This highlights the important need for therapists and therapy pro-
viders to give serious thought as to whether a particular room is ap-
propriate to use for a particular client group or issue, as certain rooms
could be unhelpful, distressing or inappropriate for some clients. This
SINCLAIR
is in fitting with Pressly and Heesacker’s (2001) recommendations. The
presence of medical equipment in the room was also mentioned by
nine survey respondents as being unhelpful.
5.12 | Data set comparison and divergence
In terms of complementarity, the data within this data set explain
and ‘flesh out’ some of the answers that respondents gave to the
quantitative questions. In terms of divergence, although 100% of
clients and therapists agreed that soundproofing was important
in the quantitative data, therapists (particularly those in the NHS)
overwhelmingly chose to write about this within the qualitative an-
swers, in comparison with few clients. Therapists spend more time
in therapy rooms than clients, and NHS staff may be more likely to
share rooms with other services, with resulting noise.
6 |  I NTE RV I E W DATA—A N A LYS I S A N D
DISCUSSION
Three overarching themes were identified, as outlined in Table  1.
These themes, along with their subthemes, will be discussed.
Interviewee information can be found in Table 2.
6.1 | Theme 1—‘Comfort’
The first theme of feeling comfortable was identified in all four
interviews and related to the physical experience of comfort that
could be felt in the room, as a result of physical needs being met. This
theme had two subthemes of 'physical needs' and 'flexible rooms'.
6.2 | Subtheme—Physical needs
The need to feel comfortable by having physical needs met was men-
tioned by all four interviewees, and the aspects of comfortable seat-
ing and temperature were mentioned by both clients and therapists.
The link between the client's physical needs for comfort being met
and their ability to relax and engage with therapy was emphasised:
If a client is sitting there and is freezing in the room…
they’re not going to want to do much… they’re just not
going to be as responsive or as comfortable…so it will
kind of block your ability as a therapist to bring them
out a bit more… I mean we have physiological needs
right…this is part of those physical needs.
(P2)
You kind of want it almost to be like a little cocoon of
comfort because you’re kind of baring your soul.
(P3)
|
      125
The aspect of lighting and the link to comfort occurred in both
therapist interviews and one client interview, with natural lighting as
a preference. One client (P3) had also experienced ‘harsh’ lighting as
negative, as it made them feel they were being ‘interrogated’. This was
also reported in data from the survey questions in the present study.
Accessibility issues were also mentioned by both therapists and
one of the client interviewees as being an important need, which,
if not met, could prove to be a hindrance to comfort and ability to
engage in the therapy session.
6.3 | Subtheme—Flexible rooms
As clients’ and therapists' needs and preferences for aspects such
as seating or seating arrangements will vary, one therapist and both
client interviewees suggested the role of flexible rooms with adjust-
able and movable seating. The relevance of seating arrangement
was also discussed by both clients, with seats too close together
or positioned directly opposite to each other described as feeling
uncomfortable. Whilst beyond the scope of this study, it is also im-
portant to consider and recognise cultural norms around personal
‘buffer zones’.
6.4 | Theme 2—‘The appearance and meaning of the
room’
This theme was related to the overall physical appearance of the
therapy room and the meaning that clients attached to the room as
a result. This theme had two subthemes of ‘clinical versus homely
rooms’ and ‘the room as a reflection of the therapist/service’.
6.5 | Subtheme—‘Clinical versus homely rooms’
Both client interviewees described how they preferred therapy
rooms to have a ‘homely ’appearance and both linked a homely ap-
pearance to their ability to relax and feel calm:
If the room felt a bit more like a home environment, it
made me feel more relaxed. It was almost like visiting
a friend and then I felt that I could be more relaxed to
TA B L E 1   Themes and subthemes from interview data
Themes Subthemes
Comfort Physical needs
Flexible rooms
The appearance and meaning of Clinical rooms versus homely
the room rooms
The room as a reflection of the
therapist
The room as a workspace Practicalities
Process and outcomes
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126       SINCLAIR

TA B L E 2   Interviewee information

Therapist or Age in No. of Amount of time as

Code client years Gender rooms client/therapist Settings experienced

P1 T 45–54 Female 16 12 yrs School, further education, university, third

sector, counsellor's house and GP surgery
P2 T 35–44 Female 30 5 yrs University, third-sector NHS psychological
therapies, counsellor's house, school, EAP
P3 C 35–44 Male 3 10 mths Third sector, counsellor's house
P4 C 25–34 Female 6 6 mths NHS psychological therapies, university,
counsellor's house, agency, GP surgery

share my thoughts and my concerns which definitely
helped the therapy
(P3).
When describing a homely appearance, accessories such as soft
furnishings, plants and artwork were often mentioned. There was also
a recognition of a fine line between a room having a homely appear-
ance and feeling ‘like someone's living room’ (P4), which may be less
helpful.
A key issue in terms of emotional/psychological needs and sense
of safety was related to the meaning of the room, particularly to cli-
ents. When a room felt a particular way, or symbolised something in
particular, this was often described within the context of a positive
or negative impact. Rooms that had a clinical or medical feel were
mentioned by three interviewees as being unhelpful or difficult. One
therapist spoke about having worked in a GP surgery and the diffi-
culties this could cause:
This interviewee felt that acknowledging the meaning of the room
to the client was important and a way of working with ‘difficult’ rooms.
‘Working with’ difficult rooms is not something that previous research
has considered, but is important to consider in settings such as the
NHS, when changing rooms often is not an option.
When asked about advice that they would give to therapists and
therapy providers about rooms, both client interviewees empha-
sised the importance of therapists/therapy providers considering
the client viewpoint and asking about their experience of the ther-
apy room:
You’ve got to really consider how the environment’s
impacting on the client. I think the counsellor really
needs to reflect on the room and, if possible, just
check that with the client themselves.
(P3)

There were things like speculums and you know med-
ical instruments available and the peak of awfulness
was having to counsel somebody who had been raped
in that context. It just felt dreadful and really inappro-
priate and really unhelpful.
(P1)
In this situation, aspects of the physical environment (medical
instruments), together with the overall medical feel of the room,
were unhelpful and potentially triggering for some clients. A client
interviewee (P4) also experienced a medical environment as mak-
ing her feel as though she was going to see a doctor, rather than a
therapist.
Similarly, providing therapy within an educational context can
present similar issues, in terms of the meaning and experiencing of
the room. One therapist described working in a secondary school,
where the designated therapy room was also the deputy head teach-
er's office (when not in use) and discussed the resulting difficulties:
I mean it was a nice room, there was nothing wrong
physically, but it was the space where people got told
off.
(P1)
6.6 | Subtheme—the room as a
reflection of the therapist/service
This subtheme was related to clients and therapists making links
between the room or building and the therapist/service. One client
(P3) spoke about a blank room that they disliked, as it did not seem
to reflect anything about the therapist. As research has shown that
people can be perceived according to their surroundings (Devlin
et al., 2009; Maslow & Mintz, 1956), it could be helpful for therapists
and service providers to consider this, particularly in terms of the
therapeutic alliance and messages they are trying to convey regard-
ing the service.
One of the therapists felt it was important that the therapist
felt some connection to the space and described the discomfort of
working in a place that she did not feel ‘fitted’ her:
I think it really helps if the counsellor feels some con-
nection to and ownership of the space, so that they
feel that it’s a kind of extension of themselves in some
way. The worst example of not having that was work-
ing in a GPs surgery…it felt like I was an alien in the
space.
(P1)
SINCLAIR
If a therapist feels uncomfortable in a space, this could potentially
have an effect on their ability to work, through distraction, feeling in-
congruent or needing to continuously ‘apologise’ for the space, as one
therapist (P1) explained.
A final aspect of the room reflecting the therapist or service
was related to the wider context that the therapy was delivered in.
One therapist and one client spoke about the reception and waiting
room as having the potential to put clients at ease and help them feel
a sense of safety or calm, or, alternatively, make clients feel more
anxious. Similarly, the journey through the building to the room was
noted as important by both therapists and both clients. This tallied
with some client survey respondents, who said they disliked having
to say their name out loud in waiting rooms and described shared
waiting rooms as making them feel nervous.
6.7 | Theme 3—‘The room as a workspace’
The final theme was related to the need for the room to be a viable space
where both client and therapist could do the ‘work’ of therapy. This
theme had two subthemes: ‘practicalities’ and ‘process and outcomes’.
6.8 | Subtheme—Practicalities
The subtheme of practicalities described the aspects of the room
and environment that contributed to a viable or non-viable work-
space for the client. The issue of the room being soundproof and not
having distractions was mentioned by three participants. Rooms not
being soundproof could risk breaching confidentiality and this was
more frequently mentioned by the therapist interviewees who had
worked in settings such as GP surgeries or educational establish-
ments. Unhelpful interruptions were commonly experienced within
GP surgeries:
The nursing staff or doctors would just knock on the
door and come in… rather than there being a kind of
real understanding that you couldn’t come in, so I
used to have to put a thing on the door saying “do not
come in” in big letters.
(P1)
It is important to remember that the therapy room is the therapist's
workspace and that therapists also have a need for containment, com-
fort, safety and a suitable room free from distractions, to carry out the
work. This was frequently mentioned by therapists in the qualitative
survey data and highlighted by one client and two therapist interview-
ees. One therapist spoke about a private therapy setting that she had
and how this enabled her work:
I felt that space helped me do my job and it felt safe
and it felt contained.
(P1)
|
      127
This contrasted with a time that she had worked in a GP surgery,
with little control over the room, where she had to ‘make excuses’ for
the room to the client.
6.9 | Subtheme—Process and outcomes
In terms of the ideal, both therapists spoke about the room ideally
reflecting and enhancing the therapy process. When rooms are
unsuitable or not maintained, as well as possibly communicating
something about the service, this could also have an effect on the
client:
Walking into a space that values them, you know
that bothers to make a clean space or a comfort-
able space… so I think when we were in our previous
building… sort of the woodchip walls and smelling of
smoke and feeling filthy and uncared for; I just think
it must have felt like coming in like being Cinderella or
something and coming into a Cinderella place.
(P1)
Both therapists felt that the room was very important, with one
suggesting that it had the potential to add to the ‘warmth’ of the expe-
rience and enhance the therapeutic alliance. There was a further link
made between the quality of the setting and containment and enabling
of the process of the work:
The room also needs to be able to contain what’s hap-
pening; so, I think the room, if it’s not a good setting
has a huge role in kind of stifling the process that the
client can undergo in the space.
(P2)
6.10 | Data set comparison
Although there was much convergence with the quantitative and
qualitative survey data, in comparison with the qualitative survey
data, interviewees did not simply give long lists of features of rooms,
but instead rooted and described features of the room within their
own experiences. This storied account allowed for a deeper under-
standing of why particular features were helpful or unhelpful; this is
also a difference to previous research in this area.
7 | CO N C LU S I O N
The findings suggest that the physical environment of the therapy
room is important to clients and therapists and can play an impor-
tant role in enabling clients and therapists to feel safe, comfortable
and more able to engage with the therapeutic process. The aspects
of the room that were most important to clients were comfortable
 |
128       SINCLAIR
seating (adjustable and moveable), comfortable room temperature,
soundproofing, no interruptions and room accessibility. Clients ex-
plained that feeling comfortable and ‘safe’ (not overheard, triggered
or likely to be interrupted) in a therapy room enabled them to open
up and talk more. The physical environment of the room was also
seen by clients and therapists as important in encouraging an effec-
tive therapeutic relationship.
Whilst these findings may not be surprising, many therapists,
particularly those working in the NHS and educational settings, con-
tinue to have to use rooms that are less than ideal for conducting
talking therapies. This can hinder the process of therapy and poten-
tially impact the therapeutic relationship. It is hoped that this study
will provide important evidence to service providers and practi-
tioners of the importance of considering the physical environment of
the therapy room and ensuring that therapy rooms are comfortable,
free from noise/interruption and appropriate for the client group/
issue being discussed. As clients’ preferences and needs are differ-
ent, it is important that therapists talk to clients about the room;
this is especially important when there are difficulties with the room.
Therapists working in the NHS usually have less control over
therapy rooms than private practitioners and can be affected by
room issues related to the wider setting. Loud noises from corridors,
poorly soundproofed rooms and motion-controlled harsh lighting
can be hindering to the therapy process, particularly when work-
ing with traumatised clients with an increased startle response.
Therapists and service providers need to consider whether partic-
ular settings may be inappropriate for particular client groups or
whether adjustments can be made, such as seeing trauma clients at
quieter times. Rooms with a clinical/medical-type appearance were
overwhelmingly described in negative terms by clients and thera-
pists, and the presence of medical equipment was experienced as
unhelpful.
A summary of findings and implications for practice and policy
is as follows:
• Rooms with a clinical/medical appearance are not favoured by
therapists and clients and are often experienced as unhelpful.
• Comfortable, adjustable and moveable seating is particularly im-
portant to clients and therapists.
• The soundproofing and lighting of therapy rooms is important to
consider when delivering certain types of therapy, such as trauma
therapy or imaginal exposure.
• The therapy room is the therapist's workspace and needs to be
comfortable and practical for the therapist.
• Service providers need to ask clients for feedback about therapy
rooms to ensure that rooms are meeting their needs
7.1 | Strengths of this study
Qualitative and quantitative data were gathered from actual clients
and therapists in the UK, who had experienced therapy rooms in a
wide range of settings. This provided a rich data set and an in-depth
view of the impact and experience (including emotional experience)
of the physical environment of therapy rooms. This more nuanced
picture from a mixed-methods design is a significant difference to
most research in this area. This is also the first study that has looked
at NHS therapy rooms in primary and secondary care.
7.2 | Limitations of this study
Participants viewing the therapy room as important could have
been more likely to participate, due to the sampling methods used.
Furthermore, data were not gathered about the ethnicity of partici-
pants, due to data protection issues in gaining ethical approval for
the study; cultural differences could affect clients’ or therapists’ ex-
perience of therapy rooms. It would have strengthened the findings
to have had more male participants.
The relatively small number of participants limits the generalis-
ability of the findings; however, many of the findings are in fitting
with the majority of existing literature (Backhaus, 2008; Pearson &
Wilson, 2012; Pressly & Heesacker, 2001).
7.3 | Further research
There is a need for further research into the potential interaction
between clients’ presenting issues and the room and the effect of
cultural differences upon the experience of therapy rooms.
AC K N OW L E D G E M E N T S
I would like to thank the client and therapist participants who took
part in this research, sharing their valuable thoughts and experiences
of therapy rooms and the NHS trust and service managers who
agreed to host this research. Thank you also to Professor Gemma
Moss for her help and insight, particularly around data interrogation
within mixed-methods research.
ORCID
T. Sinclair  https://orcid.org/0000-0001-5988-0661
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AU T H O R B I O G R A P H Y
T. Sinclair is a qualified counsellor and completed this research as
part of an MSc in the Psychology of Education at the University
of Bristol. She has worked as a counsellor/therapist within NHS,
third sector, university and secondary school settings and is cur-
rently working within a research clinic. Her research interests are
the physical environment of the therapy room, mixed methods
and coproduction in research. Contact: tssinclair2@gmail.com.
How to cite this article: Sinclair T. What’s in a therapy
room?—A mixed-methods study exploring clients’ and
therapists’ views and experiences of the physical
environment of the therapy room. Couns Psychother Res.
2021;21:118–129. https://doi.org/10.1002/capr.12376
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