Dear Therapists, a Reminder That the Physical Setting of Therapy Really Matters

For the third time since starting therapy, my therapist has changed their office. I know it may sound silly to some people, but for trauma survivors, physical safe space is a big deal and hard to come by.

• What is PTSD?

My therapist’s office is like an oasis to me. I know where everything is. Every book, every picture, every clock. When I notice myself getting triggered in session and unable to look her in the eyes, I seek out these familiar objects… taking in the smell in the room, the sound of the clocks ticking, the AC humming, and I acknowledge the soothing way in which the couch cradles my body. All of this helps to ground me and anchor me, allowing me to continue effectively engaging in the session. So the change of space is a huge adjustment and can be somewhat dysregulating.

Therapy has as much to do with the space as it does the therapist and small changes can be extremely powerful in terms of our sense of security within the therapeutic environment. This is important to discuss and to acknowledge. A good trauma therapist will be aware of it and delve into the implications it might have. It might even create an opportunity to explore further aspects of our trauma, particularly if our trauma involved a type of dissociation that included a hyperfixation on our environment to help us feel safer. The failure of a therapist to address this in a nonjudgmental way is not only a missed opportunity, it can be downright damaging to the therapeutic alliance.

The first time I experienced this was with my now ex-therapist who, as I have written about in previous articles, wasn’t exactly the most trauma-informed and could behave in extremely flippant ways, dismissing my feelings about things or downright shaming me for these feelings. About three years into therapy, she completely remodeled her office from the waiting room to the therapy room. New paint, new furniture, new art… everything changed. And it occurred without any kind of warning. When I had returned from the Christmas break, which can be stressful in and of itself due to the extended time away from therapy, I was met with a completely foreign environment.

If I’m being honest, I was upset. And instead of her bringing it up at the beginning of the session, she acted like nothing happened. In the moment, I felt too embarrassed to say anything, so I just mumbled something about the new color of the walls and left it at that. The next week I mentioned that it felt weird to be sitting on the other side of the room. Her response was, “It’s my office and I have the right to redecorate it if I feel like it.” While that’s absolutely true, not acknowledging how it can affect your patient is a little glib and definitely not patient-centered care in my opinion.

The second time this occurred, my eye movement desensitization and reprocessing (EMDR) therapist was moving to a different location a few blocks away. We had discussed the upcoming move at great length prior to it occurring so I had prepared myself for it. The office was much larger and the decor very different, but we spent a couple of sessions discussing it to get comfortable together. We discussed my feelings about it and I was encouraged to ask questions about things like the placement of the clocks and certain pieces of art. I felt included in the process and like my needs and concerns were important to her. I adjusted just fine and as the years went by it became my “home away from home.”

Cue COVID-19, and all of a sudden going to the office wasn’t an option. None of us knew when we’d be going back to in person sessions and we switched to telehealth. This was unwelcome to many, but to me, it was an adjustment that never really felt good. It was better than nothing, but I couldn’t achieve that level of safety that I felt in the office from my bedroom, car, kitchen, or wherever else I could find a modicum of privacy to do a session.

That being said, I applaud my therapist for the way she handled things. When she had to do sessions from home, she would tell me where in her house she was and would almost give me a virtual tour of the area surrounding her to help anchor me. When she did sessions from her office, she’d move her screen around to show me where she was within the space to situate me within the context of the room. I don’t know if she did this instinctually or had been trained to do this, but I cannot express how helpful that was. It wasn’t perfect, but it did at least acknowledge the elephant in the room… the screen between us separating us.

I’d like to take a quick detour here to mention a couple of do’s and dont’s with regard to telehealth. I recently heard a podcast discussing a therapist who was conducting sessions from home because she had to care for her young children. The children were in the room with her while she did sessions. While they were likely too young to absorb any of what was being said, the client was understandably perturbed by this.

I think all of us can appreciate the challenges posed by COVID-19 and many of us had to juggle home and work life. However, in a situation where privacy is of utmost concern and necessity, any kind of violation of that is a no-go. Additionally, having repeated distractions to a telehealth session, like pets, other noise, phones ringing, or text notifications is disruptive and puts an even greater monkey wrench in the ability of a patient to connect in any meaningful way to a therapist via telehealth.

Returning to the office… the most recent move occurred last week. The facility where my therapist practices was expanding and a larger new office opened up. Understandably, she decided to relocate to this office. Like before, she brought up the likelihood of this move before she had even finalized it. Knowing that I’ve experienced a disruption several times before and am particularly sensitive to it, she wanted to begin the process of my adjusting as early as possible.

Over the two or so months prior to the move she would bring it up, ensuring me that nothing in her office was going away but perhaps would be relocated. We talked about favorite objects to look at, my “protection pillow,” the memorabilia she had, and the arrangement of her chair in relationship to the couch I sat on. Nothing was off-limits.

By the time of the move, I had already steeled myself for the change, reminding myself that the most important component of therapy (my therapist) was still there and she’d work with me to feel safe in our new space. As she came to retrieve me for our session, my heart was pounding, partly out of anticipation of what the new space would look like, partly wary of not being able to locate my safe objects. As we walked down the winding corridor for some reason I blurted out, “I feel like I’m doing the walk of shame.” I tend to make silly jokes when I’m uneasy.

Once we got to the office, she gave me a tour. The space was at least twice the size of her other office so it’s not quite as cozy. She made sure to point out all my favorite things, adjusted my view of things I couldn’t see well and eased into the session allowing me to just do some visual nesting in the space. All in all, it was awkward, but not intolerable. I’m sure that with time I’ll be able to relax into the room and regain my equilibrium there.

Ambiance is a crucial element in any setting, be it a restaurant, business office, or hotel. Designers and architects go to great lengths to factor in every element of the consumer experience, incorporating things like elements of Feng Shui and bringing nature inside. So to think that it doesn’t influence the therapeutic environment would be illogical. What I am arguing is that when a vulnerable population that is hypervigilant and uniquely susceptible to the tiniest changes is involved, the layout and design of a therapist’s office is critically important.

The office should certainly reflect the personality and taste of the therapist, but not to the detriment of or at the expense of the comfort and security of their patients. Being aware of any specific needs, like no strong smells or the avoidance of images that may evoke a traumatic memory, is something a therapist must keep in mind. And encouraging open dialogue about the space with patients is absolutely critical, particularly when any changes are made.

And for patients, know that your reaction to the therapy environment isn’t frivolous… it matters. You are there to process trauma, learn new coping skills, and to push yourself to be vulnerable. If anything in the space is hindering your growth and healing, your therapist needs to know about it. Too hot or cold? Too bright? Can you hear people in the waiting room? Whatever it is, don’t be afraid to ask for what you need. An ethical therapist will willingly discuss this with you and whenever possible, they will do what they can to make you feel as comfortable and safe as possible.