Understanding Student Perspectives of University Counseling Centers by Rachel Jupina

Understanding Student Perspectives of University Counseling Centers

Rachel Jupina M.A. Interior Design, Non-Thesis Project 2021 Committee Chair: Alana Pulay, PhD Committee Members: Minyoung Cerruti, PhD, Judy Theodorson, M.Arch, Andrew Parker, M.Arch

Table of Contents Abstract............................................................................................................................................................................ii List of Tables...............................................................................................................................................................iv List of Figures..............................................................................................................................................................v 1. INTRODUCTION 1.1 Background................................................................................................................................................2 1.2 Purpose.......................................................................................................................................................3 1.3 Literature Review............................................................................................................................4-6 Spatial Settings................................................................................................................................4 Effects on Behavior.......................................................................................................................5 Positive Distractions.....................................................................................................................6 1.4 Theoretical Framework Roger Ulrich’s Theory of Supportive Design.............................................................7 1.5 Research Questions..........................................................................................................................9 1.6 Case Studies....................................................................................................................................10-21 Case Study Analysis Introduction..............................................................................10-11 McLeod Tyler Wellness Center....................................................................................12-13 Duke University Student Wellness Center.........................................................14-15 UVA Student Health & Wellness Center.............................................................16-17 SUNY Oneonta Counseling Center.........................................................................18-19 Case Study Analysis..........................................................................................................20-21 2.RESEARCH DESIGN AND METHODOLOGY 2.1 Methodology Variables and Process.....................................................................................................22-23 2.2 Survey Components Survey Part 1...........................................................................................................................24-25 Survey Part 2..........................................................................................................................26-27

3. IMPLICATIONS 3.1 Survey Demographics.......................................................................................................28-29 3.2 Quantitative Survey Results and Discussion...............................................30-39 3.3 Qualitative Survey Results...........................................................................................40-43 3.4 New Spaces Survey Results......................................................................................44-45 3.5 Conclusions.............................................................................................................................46-47 3.6 Limitations.........................................................................................................................................48 3.7 Future Directions...........................................................................................................................49 4.REFERENCES.........................................................................................................................................50-51 5.APPENDIX 5.1 Problems and Goals....................................................................................................................52 5.2 Literature by Space............................................................................................................53-54 5.3 Case Study Analysis..........................................................................................................55-56 5.4 WSU Counseling and Psychological Services....................................................57 5.5 IRB Approval............................................................................................................................58-59 5.6 Survey Questions.................................................................................................................60-65 5.7 Quantitative Results...........................................................................................................66-69 5.8 Qualitative Process..............................................................................................................70-73

Abstract

This study begins to explore how interior design elements can be used in college counseling centers to reduce stress and stigma and increase access. College students often struggle with their mental health and there is a lack of studies on how the interior space can be used to mitigate these problems. Roger Ulrich’s Theory of Supportive design is implemented in this study to understand if it can alleviate these issues. The theory works in three parts: sense of control, social support, and positive distractions. Four spaces in the WSU Counseling Center environment were chosen, the entry, the waiting room, a counseling room, and a group counseling room. Design elements identified from the literature review and case study analysis that supported the theoretical framework, were applied into each new space to compare to the existing. Students’ reactions to the space were then recorded through a survey. This survey measured the effectiveness of the new design elements based on stress, feelings of stigma and usage of the space.

iii

List of Tables 1. Roger Ulrich’s Theory of Supportive Design..................................................................7 2. Case Study Analysis.....................................................................................................................20 3.1. Likert Scale: Room Perception...........................................................................................25 3.2. Likert Scale: Room Perception.........................................................................................27 4.1 Positive Affect Overall Frequencies................................................................................40 4.2 Positive Affect per Person Frequencies.....................................................................40 5. Q36 Positive Affect Results.....................................................................................................41 6.1 Negative Affect Overall Frequencies.............................................................................42 6.2 Negative Affect per Person Frequencies..................................................................42 7. Q37 Negative Affect Results...................................................................................................43 8. Problems and Goals.......................................................................................................................52 9. Literature by Space................................................................................................................53-54 10.Case Study Analysis.....................................................................................................................55 11. Q8 Likert Scale.................................................................................................................................61 12. Space Perception and Stress Likert Scale...............................................................62 13. Space Perception and Stigma Likert Scale.............................................................63 14. Space Perception and Usage Likert Scale...............................................................64 15. New Spaces and Usage Likert Scale............................................................................65 16. Entry T-test Results.....................................................................................................................66 17. Waiting Room T-test Results.................................................................................................67 18. Counseling Room T-test Results.......................................................................................68 19. Group Counseling Room T-test Results......................................................................69 20.1 Qualitative Process-Positive Effect..............................................................................70 20.2 Qualitative Process-Positive Effect.............................................................................71 21.1 Qualitative Process-Negative Effect.............................................................................72 21.2 Qualitative Process-Negative Effect............................................................................73 21.3 Unique Before and Afters.....................................................................................................73

List of Figures 1. McLeod Tyler Wellness Center Room Analysis..........................................................13 2. Duke University Student Wellness Center Room Analysis..............................15 3. UVA Student Health and Wellness Center Room Analysis..............................17 4. SUNY Oneonta Counseling, Health, and Wellness Room Analysis..........19 5. Room Analysis Comparison......................................................................................................21 6. Participant School Year...............................................................................................................28 7. Participant Gender............................................................................................................................28 8. Counseling Services Location................................................................................................28 9. Counseling Center Usage..........................................................................................................28 10. Q8 Results............................................................................................................................................29 10.1 Q8 by Gender.......................................................................................................................29 10.2 Q8 by School Year.........................................................................................................29 10.3 Q8 by Previous Usage................................................................................................29 11.Q8 and Q34 Comparison............................................................................................................30 12. Entry Artwork....................................................................................................................................33 12.1 Amount of Seating in Entry.......................................................................................33 13. Artwork in New Waiting Room............................................................................................35 13.1 Waiting Room Seating Arrangement.................................................................35 14. Seating Arrangement and Stigma......................................................................................37 14.1 Artwork and/or Views in New Counseling Room..................................37 14.2 Privacy in New Counseling Room.....................................................................37 15. Seating Arrangement and Stigma in New Group Counseling....................39 15.1 Privacy and Access in New Group Counseling.......................................39 15.2 Artwork and Views in New Group Counseling.......................................39 16. New Spaces Results....................................................................................................................44 17. Location Results...............................................................................................................................45 18. WSU Counseling and Psychological Services Room Analysis.................57

1. INTRODUCTION 1.1 Background

Background

Many college students from ages 18-24 struggle with their mental health. According to a study by Xiao (2017), 96% of surveyed college counseling center directors believed the number of students with psychological problems was an issue on their campus. College counseling centers are the biggest resource that students have. Even with this resource, many students do not seek help from a professional. In a study by Miranda (2015), less than half of the students surveyed followed through with the treatment recommendations from their counseling center. The students reported a preference for dealing with problems on their own, and a fear of stigma in going to see a professional.

1. INTRODUCTION 1.2 Purpose

Purpose

While principles from healthcare studies can be applied to counseling center interiors, (Shepley, 2014) none address the stress and stigma that keeps students from using this important campus resource. Although healthcare studies have identified environmental factors that positively or negatively impact patients’ health, current knowledge of healthcare environments has mainly stemmed from pediatric and geriatric patient populations and in other healthcare settings. Thus, there is a need for an environmental study of college counseling centers, since our inadequate understanding of how college students perceive interior features contributes to the failure to eliminate fear of stigma and stress in the use of counseling centers.

Literature Review 1.3: Spatial Settings Milieu is a general term to describe one’s social environment. In behavioral health design this term is used when designers want to create therapeutic milieu, meaning a positive environment for the patient. In the past, behavioral health environments were designed to be institutional, more like a hospital. Today’s literature focuses more on how the interior environment can move away from this. According to Golembiewski’s (2015) research, the spaces should feel more homelike instead of institutional. This homelike quality allows the patient to feel more comfortable and they are more easily able to relate to the world around them. There should be a choice of wholesome things for patients to do like games with other patients and access to the outdoors.

Literature has also begun to cover how some patients may be sensitive to outside stimuli. Sensory modulation is another way patient can be stimulated positively. Mental illness can lead to impaired sensory processing so some individuals may hav e environment is key to patient’s rehabilitation. Privacy is one of the largest issues among scholars. Connellan et al., (2013), believes it is important that each space has a clear use. Clear delineation between public versus private and social spaces versus personal space helps to eliminate confusion. Color and wayfinding or simply signage that lets patients know what each space is. In past literature, bedrooms with multiple people were seen as being more effective as the patients would be able to look after

each together and prevent suicide. Currently, single rooms are seen to be the most beneficial as they reduce crowding stress, and a patient does not have to be moved around if their condition changes (Connellan et al., 2013). A more recent contribution by Golembiewski, (2015), acknowledges how furniture can impact patient mood. Homey furniture will allow patients to feel more comfortable in the space and makes for an easy transition for when they leave. Furniture should be attractive and pleasing as well as homelike. Simply creating a space that is more homely will help to reduce stress of patients and staff (Golembiewski, 2015). Designers must balance how the furniture looks and how patients will use it.

Effects on Behavior An important topic that is seen throughout the literature is how behavioral health interiors influence patient behavior. When a patient arrives to a facility there are several ways they could be feeling, which is why it is being so highly researched. One of the major issues in facilities is reducing violence and aggression among patients. Ulrich et al., (2018), proposes a model with four key elements: reducing crowding stress, reducing environmental stress, implementing positive distractions, and designing for observation. Ulrich and the research team found that when patients feel that they are being crowded their stress can increase which may lead to them acting out. Single

patient rooms with private bathrooms allow for patients to have enough privacy and they are able to get adequate rest. Research by Zeisel et al. (2003), adds to this by proposing that patients should also be able to personalize their space with pictures and other items. This can help reduce aggression as patients have ownership of their space. Communal areas should have movable seating that allow for patients to move around and regulate their personal space (Ulrich et al., 2018). Often patients feel that when they enter a facility that their control is being taken away. In the past and sometimes today behavioral health facilities were seen as restricting. Today, scholars

look for ways to give patients a sense of control and autonomy. A large amount of literature supports outdoor spaces as a way to give patients their own space and free movement. Implementing terraces or gardens gives patients spaces to wander and allow them to get out of the core of the facility (Andrade & Devlin, 2015). In a study by Ahern et al., (2016), a new renovated facility had implemented a galleria area that had different amenities for patients. Patients felt that they had increased autonomy and that the space empowered them to be able to make their own decisions. Researchers reported a strong feeling of independence as patients did not have to ask to leave to go to spaces that

were outside the inpatient area. In this study, patients were able to voice what changes they would like in the different spaces. This allowed for patients to take ownership of the space and for there to be improvements for future patients. In another study, the sense of control was enhanced when patients were able to choose the art that would be in their space (Andrade & Devlin, 2015). This gave patients a sense of customization know they could control and take ownership of their space. Overall, the literature is starting to shift more to value patient input. Patient then have an increased sense of autonomy which is important for when they leave the facility after their stay.

Roger Ulrich’s Conceptual Model to Reduce Aggression (Ulrich et al., 2018). Reduce Crowding Stress

Reduce Environmental Stress

Create Positive Distractions

Design for Observation

Positive Distractions Positive distractions have been well researched in hospitals and many of those same principles have been applied to behavioral health facilities. For many patients, being in a mental health facility can be very overwhelming and stressful. Art is one of the most common positive distractions covered in literature as it is easily accessible. In a study by Nanda et al., (2011), they found that realistic nature images and abstract representational art had the most positive responses from patients. Patients felt that they could relate to this art, so it was easy to have around. Patients did not like abstract art because they felt it was irritating and nurses felt it could be disturbing for some patients. For some the abstract art brought negative or aggressive feelings so it would not be an effective distraction. Within the literature, abstract art was consistent with negative reactions. Natural art reduced feelings and displays of anxiety and/or aggression. It was also found that having art in the facility could reduce the length of stay because there was less anxiety

(Andrade & Devlin, 2015). Although art is a strong positive distraction this research could be correlative and not causal meaning other factors could impact why patient acted differently.

Another popular implementation of positive distractions within the literature is the use of nature. Visual or physical access to nature helps to create effective positive distractions for patients (Shepley, 2014). This is also commonly referred to as biophilia. Biophilia has become a wellresearched area in healthcare and there are many theories that connect to it. Throughout the literature physical access to gardens was a repeated theme of biophilia. Gardens

that have a more natural style with flowers and vegetation tend to be the best. Researchers support this natural style as it can also attract birds, butterflies and other positive distractions making it even more successful (Shepley et al., 2016; Ulrich et al., 2018). The literature suggests that when you add views to nature and access to gardens it can help to reduce patient stress (Ulrich et al, 2018). These gardens also offer a space for privacy and socialization if needed (Ulrich et al., 2018). Overall positive distractions are a key element in reducing patient stress and anxiety.

Theoretical Framework 1.4 Table 1: Roger Ulrich’s Theory of Supportive Design Environmental Attributes:

A sense of control with respect to physical-social surroundings

Access to social support

Access to positive distractions in physical surroundings

Design Applications: Variety of seating options Ability to choose where they want to sit/be Access to privacy

Smaller activity areas Spaces that give a sense of community Outdoor sitting areas

Access to windows/ daylight/nature views Implementation of artwork

Choice to socialize or be alone 7

Research Questions

(RQ1) What are student’s perceptions of counseling centers? (RQ2) How can design features reduce stigma and stress and increase access?

Case Study Analysis For the case study analysis, four college counseling center projects were chosen. The first step taken was to analyze the images and define major features and patterns. Next, a professional from each project respectively was interviewed to get more information about the spaces, intent behind the project, and the site. This information was divided into three categories: architecture, interior, and ambiance. Following the interviews, the floor plans were analyzed, examining at the furniture placement, window size, and room size. The room size was also analyzed alongside the university student population to determine if there was a correlation. The larger universities did tend to have larger waiting rooms and multipurpose spaces. All the information was analyzed to find patterns in design elements and floor plans. The data on the furniture placement, color palette, material use, and use of positive distractions was used to influence the new design used to compare to the WSU Counseling center.

Case Studies McLeod Tyler Wellness Center College of William and Mary, Williamsburg, VA Designed by EYP

Duke University Student Wellness Center Duke University, Durham, North Carolina Designed by Duda Paine Architects

Images Courtesy of EYP ©David Sundberg/ESTO.

Images Courtesy of Dude Paine Architects

UVA Student Health & Wellness Center University of Virginia, Charlottesville, VA Designed by Duda Paine Architects and VMDO

Images Courtesy of Dude Paine Architects

SUNY Oneonta Counseling, Health and Wellness Center SUNY Oneonta, Oneonta, New York Designed by architecture+

Images Courtesy of architecture+

Case Study: McLeod Tyler Wellness Center The McLeod Tyler Wellness Center is located on the College of William and Mary campus in Williamsburg, Virginia. Prior to the project completion in 2018 buildings related to wellness like the rec center, counseling center and medical offices were spread across campus. The new wellness center allowed for a central location for all those services and created a destination for wellness. The building takes advantage of its beautiful green surroundings with curtain walls and large windows giving 70% of the building access to natural light. Biophilic principles are used throughout the design. There is an implementation of natural wood and materials as well as a water feature that creates a calming white noise. The goal of this building was to create a holistic approach to wellness. This includes the use of meditation rooms, rooms for yoga and mindfulness classes as well as informal gathering spaces for students. This is a space students want to be in regardless of use. The counseling spaces allow for privacy as well as access to views. In the counseling rooms there are multiple seating options and flexibility for the patient.

Images Courtesy of EYP ©David Sundberg/ESTO.

Room Analysis

Figure 1: McLeod Tyler Wellness Center Room Analysis Color Palette

Window Width:

Bottom floor offices on North Side ~3-6 ft Bottom floor offices on South side ~3ft Top floor offices on North side ~3ft Top floor offices on South side ~6-12ft

Case Study: Duke University Student Wellness Center Images Courtesy of Dude Paine Architects

The Duke University Student Wellness Center is located in Durham, North Carolina on the Duke campus. The old wellness center wasn’t in a central location for students. This new wellness center is located near the student center, historic quad, and athletics. The building takes advantage of the gorgeous campus views with large windows and curtain walls. Designers connect the interior to the exterior physically through an outdoor terrace as well as a meditative garden. 14

The counseling area is located on the third floor allowing for a quieter space. The building begins to eliminate stigma by providing lounge spaces and is connected to the campus Oasis space where they hold different mindfulness classes. Outside of the counseling center there is a causal gathering space with furniture that allows for privacy as well as partitions. From this space there are also great views of campus for students to look at as they work or wait to go to their appointment. The space

connects back to the landscape by utilizing reclaimed wood from the site as well as nature images from around campus. There are also quotes from different cultures around the building about wellness. Overall, the designers wanted the informal spaces to feel like a living room, making it inviting and creating a space that students want to be in. As students move up the space privacy increases and they meet the counseling center at the top.

Room Analysis

Figure 2. Duke University Student Wellness Center Room Analysis Color Palette

Furniture Use/Placement

Window Width:

NE Side- 5ft windows, typically 10ft side by side SW Side- 3’ 6”, 4’, 5’ windows 15

Case Study: UVA Student Health and Wellness Center

Images Courtesy of Dude Paine Architects

The UVA Student Health and Wellness Center is located in Charlottesville, Virginia on the University of Virginia campus. This building is part of the new construction developing on their campus. The building helps to centralize health and wellness services and will now be located near residential areas on campus. It is also much larger than the previous wellness center allowing for more students to be served. This design also utilizes the idea of a living room feel, providing many 16

lounges and informal areas for students to gather. Within these lounges spaces there is movable furniture for flexibility, a fireplace to create an inviting feel and privacy within the furniture selection. There are many wellness elements like an art therapy room, meditation rooms as well as a kitchen for cooking classes. These elements begin to introduce wellness to students even if they’re not there for therapy. The mixed-use building allows for students to enter confidently as other users may not know that they

will be going to therapy/counseling. The counseling center is located on the top floor, allowing for privacy and a quieter environment. Behind the building is a nature preserve, and the large windows let students connect back to nature and their campus. Overall the building begins to connect students to wellness and the mixed-use nature of the building meets many of the students needs.

Room Analysis

Figure 3. UVA Student Health and Wellness Center Room Analysis Color Palette/Material Use

Furniture Use/Placement

Window Width: North and South Sides: 2’-6”-3’-0”

Case Study: SUNY Oneonta Counseling, Health, & Wellness Center Images Courtesy of architecture+

The SUNY Oneonta Counseling, Health and Wellness Center is located in Oneonta, New York. The building was originally built in 1966 and was renovated in 2011. The designers’ goal was to update the space and create a design that was respectful as well as adult feeling for the students. The building is located next to a main road making it very easy for students to access. It was important to the designers to make sure the environment was comfortable. They achieve this 18

through familiar and comfortable seating, using common colors and natural wood furniture. Although this building also has primary care located in it, the counseling space has it’s own receptionist and waiting area. This allows students to feel like they have more privacy. The flow between the primary and counseling is important as it allows the staff to connect more and provide better care. The counseling rooms also have large windows that are able to bring in natural light and

give views to the greenery on campus. In the group counseling rooms it was important to make sure this is a space where people want to share. The designers used calming colors in this space as well as dimmable lighting, creating an element of choice and intimacy. The overall goal was to create a space that empowers student to communicate with others and make a space that respects its users.

Room Analysis

Figure 4. SUNY Oneonta Counseling, Health and Wellness Center Room Analysis Color Palette/Material Use

Window Width: Smaller Window ~3’ Larger Window ~6’

V - Visitor Parking AV - Admissions Visitor Parking Obtain parking permits at Netzer 110 (Building 32) Admissions Office, Welcome Center (Building 43) Hunt Union Information Desk (Building 22) University Police Parking Office (Building 2) University Police (Alumni Hall, Building 2) Dining Hall/Café Residence Halls are listed in blue

Alumni Field House

2. 3.

Alumni Hall Bacon Hall

4. 5.

Baseball Field Blodgett Hall

6. 7. 8. 9.

Bugbee Hall Chase Physical Education Counseling, Health and Wellness Center Curtis Hall

10. 11. 12. 13.

Denison Hall Fine Arts Center Fitzelle Hall Ford Hall

14. 15. 16. 17.

Golding Hall Grant Hall Hays Hall Heating Plant

18. 19. 20. 21.

Higgins Hall Hodgdon IRC Hulbert Hall Human Ecology

22. 23. 24. 25. 26. 27.

Hunt College Union Huntington Hall Lee Hall Littell Hall MacDuff Hall Maintenance Operations Center

28. 29. 30. 31.

Matteson Hall Mills Hall Milne Library Morris Conference Center

32. 33. 34. 35.

Netzer Administration Physical Science Red Dragon Field Red Dragon Outfitters

36. 37.

Schumacher Hall Science 1

38. Sherman Hall 39. Softball Field 40. Tennis Courts 41. 42. 43. 44.

Tobey Hall Track /All College Field Welcome Center Wilber Hall

45. Wilsbach Hall

Table 2: Case Study Analysis Architecture McLeod Tyler Wellness Center

-Large windows with access to natural light and views -Curtain walls -Shading elements

Duke University Student Wellness Center

-Use of natural materials -Wood and earth tones -Gathering spaces for students

-Water feature that can act as white noise -View to nature -Playing with scale

-Yoga classes, meditation rooms, massage rooms

-Large windows

-Lounge rooms

-Living room feel

-Curtain walls

-Gathering spaces

-Shading elements

-High chairs that allow for privacy

-Privacy increases as users move up through space

-Place to stop between classes

-Access to natural light

-New build

-Use of translucent materials for privacy

-Brick exterior

-Multipurpose rooms

-Living room feel

-Large windows

-Use of natural materials

-Very open

-4 levels

-Flexibility of movable materials

-New build

-Culinary space

-Access to natural light and views

-Pharmacy

SUNY Oneonta Counseling, Health and Wellness Center

Ambiance

-2 levels- New Build

-3 levels

UVA Student Health & Wellness Center

Interior

-Large windows

-Comfortable seating

-Partial brick exterior

-Soft materials

-Concrete exterior

-Natural materials

-Circular

-Common colors

-Older building renovated interior

-Separate waiting rooms

-Views of campus/nature

-Connects to nature

-Somewhat secluded on campus but off main road -Important to respect privacy -Give patients a sense of choice -Dimmable lighting

McLeod Tyler Wellness Center

Duke University Student Wellness Center

UVA Student Health & Wellness Center

SUNY Oneonta Counseling, Health, & Wellness Center

Figure 5: Room Analysis Comparison

2.1 Methodology Literature Review

Case Study Analysis

New Design to compare to WSU Counseling Center Independent Variables:

Dependent Variables

Design elements: Sense of Control • Variety of seating options • Ability to choose where they want to sit/be • Access to privacy

Level of:

Social Support • Smaller activity areas • Spaces that give a sense of community • Outdoor sitting areas • Choice to socialize or be alone Positive Distractions • Access to windows/daylight/ nature views • Implementation of artwork 22

• Stress • Stigma • Access

Methodology: Process Participants and Setting: -Students 18 years and older taking courses on WSU Pullman Campus -Survey was taken online using Qualtrics -Random Sample of 5,000 acquired through university registrar Survey Components: • Demographics: • Student Year, Gender and Use of Counseling Center • Part 1: Perception of Current Counseling Center (RQ1, RQ2) • Using renderings participants answered questions about the current campus counseling center • Part 2: Perception of Newly Designed Counseling Center (RQ1, RQ2) • Using the literature review, case study analysis and theoretical framework, new spaces will be designed • Participants answered questions regarding their perception of these spaces • Part 3: Supportive Spaces (RQ2) • Participants answered questions about supportive spaces (ex. mediation rooms, activity rooms) and how they think that would effect their experience and use of a counseling center 23

Survey Part 1

Current Entry

Current Waiting Room

Current Counseling Room

Current Group Counseling Room

Survey Questions Part 1 Example Current Entry

Q1: Please rate each of the following items on how they influence your perception of the space in terms of feelings of stress. (Q2: stigma, Q3: access/usage).

Table 3.1 Likert Scale-Room Perception 25

Survey Part 2 New Entry

Private Entrance (SOC)

New Waiting Room

Positive Distractions through graphic (PD)

Positive Distractions through graphic and Welcome Graphic (PD, SS)

Option to sit outside before entering (SOC, SS)

New Counseling Room Positive Distractions through artwork, views and plants (PD)

More Privacy (SOC)

New Group Counseling Room Positive Distractions through artwork, views and ceiling treatment (PD)

Seating arrangement allows group to be broken up (SS)

Seating arrangement and lighting allows for intimate conversation (SOC, SS)

Variety of Seating Options (SOC, SS)

Variety of Seating Options (SOC)

Survey Questions Part 2 Example New Entry

Q1: Please rate each of the following items on how they influence your perception of the space in terms of feelings of stress. (Q2: stigma, Q3: access/usage).

Table 3.2 Likert Scale-Room Perception 27

3.1 Survey Results: Demographics Response Amount

Figure 6

Figure 8

Response Amount

Figure 7 28

Figure 9

Mean Value

Q8 - Please rate the following factors on how they would impact your access/usage of the WSU counseling center.

Figure 10.2 Q8 Results by School Year

Figure 10.1 Q8 Results by Gender

Mean Value

Figure 10. Q8 Results

Figure 10.3 Q8 Results by Previous Usage 29

3.2 Quantitative Survey Results RQ1: What are student’s perceptions of counseling centers? On average, students seemed to indicate a more positive reaction to college counseling centers after viewing the new images but it did not show significance (M(dif )= -0.0096 t(103)= -0.065, p= 0.95). The students viewed four spaces, the entry, the waiting room, a counseling room and a group counseling room. The first group of images were from the existing WSU Counseling center and the second group of images was a newly designed center using Roger Ulrich’s Theory of Supportive Design. The perception of the newly designed interiors had an overall more positive response compared to the existing. This was seen through a slight increase in the mean value when asked about the perceptions of college counseling centers after viewing the second set of images.

Figure 11. Q9 and Q34 Comparison

RQ2: How can design features reduce stigma and stress and increase access? A paired two samples t-test was ran on all design elements (privacy, amount of seating, seating arrangement and artwork and/or views) for each factor (stress, stigma, and access). The use of the Theory of Supportive design seemed to have a significant effect on students when viewing the newly designed interior spaces. The t-test compared the student responses to the existing counseling center and the newly designed counseling center. This was done for each space, the entry, the waiting room, a counseling room, and a group counseling room. The observed p-values for each space indicated significance for almost every design element for each factor. This begins to indicate that the design elements derived from the Theory of Supportive were able to reduce stigma and stress and increase access to a college counseling center.

Survey Results: Entry Current Entry

New Entry

Overall, artwork/and or views created the largest impact in increasing positive influence on all three factors. In stress, stigma, and access the p-value was <0.01 for artwork and/or views. This could be due to the fact that the current counseling center has limited positive distractions. Artwork may help to mitigate feelings of stress and stigma when students are entering a counseling environment. Liddicoat (2020) supported this in an article about entries and waiting rooms stating that using natural content in the entry was seen as supportive by therapists. In addition, the implementation of seating in the entry may have also helped to relieve stress and feelings of stigma. The amount of seating options had significant p-values of <0.01 for stress. The seating arrangement had significant p-values <0.01 for stress and access. In the existing counseling entry, there were no seating options. Including a seating option before entering may have reduced stress because it allows users to pause before they enter the waiting room.

Artwork in New Entry

1=Very Negative Influence, 5=Very Positive Influence, Figure 12. Artwork in Entry

New Seating In Entry

Existing

New

Figure 12.1 Amount of Seating in Entry

Survey Results: Waiting Room Current Waiting Room

New Waiting Room

The use of privacy resulted in a substantial positive influence in the new waiting room design, the biggest influence being in stress. This could be due to the stress and stigma college students may already have towards counseling centers, privacy allowed for them to feel a larger sense of control and allow them the option to feel hidden from other users. This is corroborated by Noble and Devlin (2021), in their study on waiting rooms, participants positively responded to increased privacy. The amount of seating options resulted in the lowest impact in the new design while the seating arrangement had a more positive influence in comparison. The new seating arrangement created three different seating zones instead of just one large one. Within those zones there was movable furniture and the ability to socialize. Liddicoat (2020) notes that having movable seating arrangements and flexible layouts help to increase sense of control. In the existing space, users were closer to each other making conversation uncomfortable. The seating arrangement was more fragmented and would result in smaller zones that were closer together. This may mean that the seating arrangements in the new space provide more options for privacy and comfort. The amount of seating options had no significance among stigma or access which may indicate that seating options are not an important factor to students. This could be because they are not going to be in this space for a long time, so the number of options does not play into feelings of stigma or use of the space. Similar to the entry, artwork and/or views generated a positive affect among all three factors. Again, pointing to how that is a major element in reducing stress and increasing access. Both Noble and Devlin (2021) and Beukeboom et al. (2012) support the use of nature, plants and natural artwork as positive distractions in waiting rooms.

Artwork in New Waiting Room

Figure 13 Artwork in New Waiting Room

Seating Arrangement

Existing

New Figure 13.1 Waiting Room Seating Arrangement

Survey Results: Counseling Room Current Counseling Room

New Counseling Room

In general artwork and/or views seemed to have the biggest impact in the counseling room within the three factors. The survey results indicate p-values <0.01, identifying the significance artwork and views have. This may be because in a more intimate space like a counseling room, students may subconsciously want artwork and views to look at while they are opening up about their issues. The literature confirms that providing positive distractions help to reduce patient anxiety (Andrade et al, 2012, Shepley, 2014). This could result in users feeling more comforted by having these items in the space. Additionally, the seating arrangement created the 2nd largest positive impact between all three factors. Stress, stigma and access all had p-values <0.01 for seating arrangement. The new seating arrangement was more circular which may have been more inviting allowing for more conversation. In contrast the existing seating arrangement was more linear. This new arrangement may have given the impression it could be moved around which may give a sense of control for the user. The amount of seating options was only significant under stigma (M(dif )= -0.29, SD= 0.87, p<0.1). Allowing users to choose between a chair and couch may have mitigated their feelings towards what a counseling room typically looks like.

Seating Arrangement

Existing

New

Figure 14. Seating Arrangement and Stigma

Positive Distractions

Figure 14.1 Artwork and Views in New Counseling Room

Privacy

Figure 14.2 Privacy in New Counseling Room

Survey Results: Group Counseling Room Current Group Counseling Room

New Group Counseling Room

Privacy has a large positive impact on all three factors but especially in stress and stigma. This is demonstrated through an increase in the mean value in the new group counseling space. This could be due to the fact that group counseling can be perceived as stressful to students and may be a new experience. Allowing for some privacy may have given a sense of control or comfort (Shepley, 2014, Zeisel, 2003). Both the amount of seating options and the seating arrangement produced positive results in the new space with p<0.01 in both stress and access. The new space having two different seating arrangements may have been less overwhelming compared to the existing space, relieving stress. The existing space only had one seating type, introducing more seating options could give students a better sense of control when entering the environment (Connellan, 2013). As paralleled in other spaces, artwork and/or views had the highest positive influence in both stress and stigma. The p-values for positive distractions in the group counseling room were the lowest among all the spaces. The positive distractions that were implemented (wall art and ceiling fixtures) may have given students something else to look at besides their peers allowing their stress to be reduced. They may have also been aesthetically pleasing making students want to access this space more than the existing design.

Seating Arrangement

Existing

New

Figure 15. Seating Arrangement and Stigma

Privacy

Positive Distractions

Figure 15.1 Privacy and Access in New Group Counseling Room

Figure 15.2 Artwork and Views in New Group Counseling Room

3.3 Qualitative Survey Results What is it about a counseling center design that would positively affect your experience in terms of stress and/or stigma?

Students answered an open-ended question detailing what design elements or features would allow them to have a positive experience in a counseling center. There were 75 responses from the 104 participants. The answers were analyzed and patterns in the responses were found. The answers were then divided into three categories: spatial, emotional, and physical. In the physical category students noted that with increased privacy they were able to feel more comfortable within the space. It was also important to have openness that balances with privacy. Many adjectives were repeated in the emotional category. Overall students want to feel welcomed into the environment where they can feel comforted. The feeling within counseling spaces should be quiet and calm as it helps to create a more positive experience. Lastly, for physical elements artwork and nature were brought up, connecting back to the importance of positive distractions. Soothing lighting and colors are major elements that help to create a positive environment for students.

Overall Frequency

Table 4.1 Positive Affect Overall Frequencies

Frequency per Person

Table 4.2 Positive Affect per Person Frequencies

Spatial Open “it being open yet still have your privacy, as well as have places for open work to be able to work with others.” “I feel that having a more open and comforting space” “Being open, views of nature” Privacy “seating options that allow privacy” “There is privacy at the check in desk” “privacy/sections of larger groups” “it being open yet still have your privacy”

Emotional

Physical

Welcoming/Inviting -“Welcoming, warm, a place that students would want to go” -“It feels more welcome” -“Giving a more home-y touch to the center makes the experience more welcoming and accepting” -“A relaxed and welcoming environment would positively affect my experience.” -“Seems more inviting and welcoming which relaxes the patient and makes them more comfortable.”

Artwork -“Beautiful artwork” -“Pleasant art work” -“interesting art” -“bright colors/artwork” -“nature-themed art”

Calm -“A counseling center…that brings a sense of calmness would reduce stress (anxiety)” -“A calm, quiet, and relaxing environment” -“if a room is more calming it tends to also calm me down too”

Colors -“Some colors besides brown and beige” -“Definitely more art and color” -“Light colors (not too bright)” -“Warm colors” -“vibrant colors” -“bright colors/artwork”

Quiet “a calm, quiet, and relaxing environment” “Some quiet music might be nice for the waiting area.” Comfortable -“uplifting positive art that makes people feel comfortable and happy” -“I have to feel safe and comfortable in the space where I require such vulnerability.” -“being able to do what you’re comfortable with such as just one on one talking without small groups”

Nature -“Seeing nature” -“nature-themed art” -“views of nature”

Lighting -“easy on the eyes lights” -“Low warm lights” -“natural lighting, but also low lighting in some areas.” -“Better less offensive lighting it is very bright. Better use of daylight”

Table 5. Q36 Positive Affect Results

Qualitative Survey Results What is it about a counseling center design that would negatively affect your experience in terms of stress and/or stigma?

Students answered an open-ended question detailing what design elements or features would cause them to have a negative experience in a counseling center. There were 75 responses from the 104 participants. The answers were analyzed and patterns in the responses were found. The answers were then divided into three categories: spatial, emotional, and physical. The answers in the spatial category also include privacy again making it clear that the lack of privacy makes users feel uncomfortable. Open is also repeated, showing the balance of privacy and openness is a key factor to students. Spaces that fee cramped or crowded also begin to increase student stress. In the emotional category many phrases came up like, sterile, clinical, cold, and hospital. Overall students do not like the feeling of a clinical space or hospital. This may mean that students do not want to feel like a patient or feel like they are there because they have a problem. Students want the space to feel more welcoming and less like an office or hospital environment. Lastly, colors were mentioned again, students stating that if there is too little or too much color it can make them have negative feelings, again supporting the use of soothing colors.

Overall Frequency

Repeats from Positive Effect

Table 6.1 Negative Affect Overall Frequencies

Frequency per Person

Table 6.2 Negative Affect per Person Frequencies

Spatial

Emotional

Privacy -“There is still not too much privacy. I might like another separating apparatus in the waiting area,” -“has a general lack of privacy” -“If there is no privacy”

Uncomfortable -“uncomfortable chairs that look an AA meeting” -“I may just feel uncomfortable in the waiting until I go back into one of the 1-on1 rooms to talk with a counselor.” -“Uncomfortable seating makes me more nervous.

Open -“A more open space with a larger group makes me clamp up about my own issues” -“An open or big room” -“Too much wide open space.”

Sterile -“Having a sterile space that does not feel welcoming” -“How cold/sterile it feels” -“Overly fluorescent or sterile feeling.”

Close/small/tight/cramped/ crowded -“One of the group counseling rooms looks small and has a small amount of chairs.” -“Rooms that are too big or too small might make me feel exposed and vulnerable or trapped and slightly claustrophobic” -“An open or big room, or one of those small ones the look like a hallway with little seating” -“Tight spaces and no windows” -“crowded room”

Physical Colors -“Barren walls with boring colors (white, tan, brown, etc.)” -“lack of color” -“dark colors” -“Too many loud colors” -“Too many different colors”

Clincial/Cold -“How cold/sterile it feels;” -“Feels cold, like a hospital” -“it’s also just cold and has a general lack of privacy” -“Feeling cold (color and materials)” Old -“Bland, old, scary to walk into” -“The old design is very familiar and reminds me of my doctors office at home” Bland/Boring -“Bland, old, scary to walk into” -“Don’t want a bland office space” Hospital -“don’t want the clinical/hospital feeling.” -“I don’t want to feel like I’m in a clinic or hospital.”

Table 7. Q37 Positive Affect Results

3.4 New Spaces Survey Results Q35: These are new spaces that do not exist in our current counseling center. We want to know how they may impact your experience. Please rate the following spaces on how they would impact your usage of a counseling center.

Figure 16. New Spaces Results

Q38: Where do you think the counseling center should be located? (click anywhere on map) 86 Responses

Current Location

0 Figure 17. Location Results

Frequency of Selection per Person

3. IMPLICATIONS Conclusions 3.5

Conclusions Privacy

Through the qualitative results and the many of significant p-values throughout the quantitative results, privacy seems to be one of the students’ largest concerns. Students did not specifically say how privacy should be implemented but it is clear it has a significant effect on their experience. The increase of privacy lowered the amount of stress and stigma, supporting the use of Roger Ulrich’s Theory of Supportive design. When it comes to designing, privacy could be created through partitions or seating that has a taller back or sides. It can also be increased by breaking up the space into multiple seating areas as done in the waiting room and group counseling space. The less exposed students feel the less stress and stigma is experienced. Possible Design Solutions:

ShawContract

Eckenhoff Sanders Architects

Seating Arrangement

Positive Distractions

When it comes to seating, the arrangement had more significant p-values compared to the amount of seating options. This shows that the amount of options does not matter as much to students, especially when they may only be in some spaces for a brief moment, like the entry or waiting room. These seating arrangements were to allow for an increase of social support in adherence to the Theory of Supportive Design. In many of the spaces the new seating arrangements resulted in significance p-values, supporting the theory. In spaces like the waiting room and group counseling room, the seating arrangements should be more circular and broken up into smaller groupings. This allows for more communication and in smaller groupings users do not feel like they are exposed to everyone within the space. Movable seating is also preferred through the survey results and literature.

Students reacted positively to positive distractions in all spaces among all factors. Artwork and nature were also mentioned frequently among what would positively affect their experience. This is supported by current literature, both Noble and Devlin (2021) and Beukeboom et al. (2012) support the use of nature, plants and natural artwork as positive distractions in waiting rooms. Liddicoat (2020) also backed this in an article about entries and waiting rooms stating that using natural content in the entry was seen as supportive by therapists. Overall the literature states that providing positive distractions helps to reduce patient anxiety (Andrade et al, 2012, Shepley, 2014,). The recommendation here would be to include artwork that students can relate to which may be nature related or visually stimulating. Students also enjoy the natural light so having large windows where students can see outside would be preferred. Including physical plants in the waiting rooms and counseling rooms may also be beneficial in reducing student stress and feelings of stigma.

Possible Design Solutions:

Kwalu Furniture

Possible Design Solutions:

Steelcase

Huffaker Associates

HCD Magazine

3. IMPLICATIONS Limitations 3.6

Limitations Some limitations to the study may have to do with student’s prior biases towards this counseling center or counseling in general. Students that have used this counseling center before and possibly had bad experiences may have rated the counseling center lower. The same could be said about students that have had positive experiences at this counseling center could rate it higher. Students may have had preconceived notions about counseling that may have impacted how they rated the spaces. The study also did not explain what floor this counseling center is on. Students may have rated privacy or views of nature differently if they knew they were on the first floor versus the third. The study also only had 104 participants and only 75 of which that completed the open-ended questions. This could make it harder to extrapolate this data to other college counseling centers.

Future Directions Throughout the literature there are a good number of studies on waiting rooms and entry spaces, and counseling or therapy rooms. But there are almost no studies on group counseling rooms. In the future it would be important to study group counseling rooms on or off a college campus because many people may feel stressed going into this environment. This is also a space where many people at once must feel vulnerable so it would be important to see how these individuals can be supported through design. The current study could also be implemented on other college counseling centers as students may have different reactions to the space based on their area of the country or world. Future directions could also focus on supportive spaces like yoga rooms, meditation rooms, and multipurpose rooms. Studies could begin to explore that if the implementation of these spaces helps to reduce stress and stigma and if they make users more likely to use the space. In general, there are very few studies on college counseling center interiors so it could be important to repeat this kind of study on other college campuses.

3. IMPLICATIONS Conclusions 3.7

References Ahern, C. C., Bieling, P., McKinnon, M. C., McNeely, H. E., & Langstaff, K. (2016). A Recovery-Oriented Care Approach. Journal of Psychosocial Nursing, 54(2), 39-48. Andersen, C., Kolmos, A., Andersen, K., Sippel, V., & Stenager, E. (2017). Applying sensory modulation to mental health inpatient care to reduce seclusion and restraint: A case control study. Nordic Journal of Psychiatry, 71(7), 525–528. https://doi.org/10.1080/08039488.2017.1346142 Andrade, C. C., & Devlin, A. S. (2015). Stress reduction in the hospital room: Applying Ulrich’s theory of supportive design. Journal of Environmental Psychology, 41, 125–134. https://doi.org/10.1016/j.jenvp.2014.12.001 Bazley, C., Vink, P., Montgomery, J., & Hedge, A. (2016). Interior effects on comfort in healthcare waiting areas. Work, 54(4), 791–806. https://doi.org/10.3233/WOR-162347 Beukeboom, C. J., Langeveld, D., & Tanja-Dijkstra, K. (2012). Stress-Reducing Effects of Real and Artificial Nature in a Hospital Waiting Room. The Journal of Alternative and Complementary Medicine, 18(4), 329–333. https://doi.org/10.1089/acm.2011.0488 Connellan, K., Gaardboe, M., Riggs, D., Due, C., Reinschmidt, A., & Mustillo, L. (2013). Stressed Spaces: Mental Health and Architecture. HERD: Health Environments Research & Design Journal, 6(4), 127–168. https://doi.org/10.1177/193758671300600408 Doroud, N., Fossey, E., & Fortune, T. (2018). Place for being, doing, becoming and belonging: A meta-synthesis exploring the role of place in mental health recovery. Health & Place, 52, 110–120. https://doi.org/10.1016/j.healthplace.2018.05.008 Golembiewski, J. A. (2015). Mental health facility design: The case for person-centred care. Australian & New Zealand Journal of Psychiatry, 49(3), 203–206. https://doi.org/10.1177/0004867414565477 Kasmar, J. V., Griffin, W. V., & Mauritzen, J. H. (1968). Effect of environmental surroundings on outpatients’ mood and perception of psychiatrists. Journal of Consulting and Clinical Psychology, 32(2), 223–226. https://doi.org/10.1037/h0025618 Liddicoat, S. (2020). The Therapeutic Waiting Room: Therapist and Service User Perspectives on the Psychologically Supportive Dimensions of Architectural Space. HERD: Health Environments Research & Design Journal, 13(2), 103–118. https://doi.org/10.1177/1937586720904805 Miranda, R., Soffer, A., Polanco-Roman, L., Wheeler, A., & Moore, A. (2015). Mental Health Treatment Barriers Among Racial/Ethnic Minority Versus White Young Adults 6 Months After Intake at a College Counseling Center. Journal of American College Health, 63(5), 291–298. https://doi.org/10.1080/07448481.2015.1015024

Miwa, Y., & Hanyu, K. (2006). The Effects of Interior Design on Communication and Impressions of a Counselor in a Counseling Room. Environment and Behavior, 38(4), 484–502. https://doi.org/10.1177/0013916505280084 Mochizuki-Kawai, H., Matsuda, I., & Mochizuki, S. (2020). Viewing a flower image provides automatic recovery effects after psychological stress. Journal of Environmental Psychology, 70, 1-9. https://doi.org/10.1016/j.jenvp.2020.101445 Nanda, U., Eisen, S., Zadeh, R. S., & Owen, D. (2011). Effect of visual art on patient anxiety and agitation in a mental health facility and implications for the business case: Visual art and mental health. Journal of Psychiatric and Mental Health Nursing, 18(5), 386– 393. https://doi.org/10.1111/j.1365-2850.2010.01682.x Nasar, J. L., & Devlin, A. S. (2011.). Impressions of Psychotherapists’ Offices. Journal of Counseling Psychology, 58(3), 310-320. Noble, L., & Devlin, A. S. (2021). Perceptions of Psychotherapy Waiting Rooms: Design Recommendations. HERD: Health Environments Research & Design Journal, 1-15. https://doi.org/10.1177/19375867211001885 Sanders, R., & Lehmann, J. (2018). An exploratory study of clients’ experiences and preferences for counselling room space and design. Counselling and Psychotherapy Research, 19, 57-65. https://doi.org/10.1002/capr.12202 Shepley, M. M., Pasha, S., Ferguson, P., Oproescu, G., Huffcut, J. C., Young, J., Kiyokawa, G., Zadeh, R. S., Martere, J., Zborowsky, T., Meyerhoeffer, T., Zimring, C., & McDermott, B. (2014). Design Research And Behavioral Health Facilities. 1-81. Shepley, M. M., Watson, A., Pitts, F., Garrity, A., Spelman, E., Kelkar, J., & Fronsman, A. (2016). Mental and behavioral health environments: Critical considerations for facility design. General Hospital Psychiatry, 42, 15–21. https:doi.org/10.1016/j.genhosppsych.2016.06.003 Snethen, G., Jeffries, V., Thomas, E., & Salzer, M. (2021). Welcoming places: Perspectives of individuals with mental illnesses American Journal of Orthopsychiatry, 91(1), 76–85. https://doi.org/10.1037/ort0000519 Ulrich, Roger. (1997). A theory of supportive design for healthcare facilities. Journal of healthcare design: proceedings from the ... Symposium on Healthcare Design. Symposium on Healthcare Design, 9, 3-7; discussion 21. Ulrich, R. S., Bogren, L., Gardiner, S. K., & Lundin, S. (2018). Psychiatric ward design can reduce aggressive behavior. Journal of Environmental Psychology, 57, 53–66. https://doi.org/10.1016/j.jenvp.2018.05.002 Xiao, H., Carney, D. M., Youn, S. J., Janis, R. A., Castonguay, L. G., Hayes, J. A., & Locke, B. D. (2017). Are we in crisis? National mental health and treatment trends in college counseling centers. Psychological Services, 14(4), 407–415. https://doi.org/10.1037/ser0000130 Zeisel, John, Silverstein, Nina M, Hyde, Joan, Levkoff, Sue, Lawton, M Powell, & Holmes, William. (2003). Environmental correlates to behavioral health outcomes in Alzheimer’s special care units. The Gerontologist, 43(5), 697–711. https://doi.org/10.1093/geront/43.5.697

5.1 Appendix: Problems and Goals Calm/De-Escalate

Reduce Stigma

Create Positive Distractions

-“Provide indoor and outdoor spaces for therapeutic activities” (Shepley, 2014) -Welcoming reception area (Shepley, 2014) -Use modular furniture so it can be rearranged (Shepley, 2014) -”Spaciousness, views to the outside, and privacy were the most positively received elements of the new space.” (Shepley, 2014) -More privacy/more personalization reduced anxiety (Zeisel, 2003) -Patients can lose privacy in high density environments (Connellan, 2013) -Communal areas with moveable seating and ample space, low social density and noise reduction reduced aggression (Ulrich, 2018) -Rooms with amenities like TVs and social areas helped to reduce stress (Andrade, 2014) -Dim light counseling rooms allowed patients to feel more relaxed (Miwa, 2006)

-“Provide day rooms and common areas that encourage social interaction and promote sense of community” (Shepley, 2014) -“Locate a mix of seating arrangements that support social interaction between different groups of patients”(Shepley, 2014) -”Smaller activity space creates stronger sense of community” (Shepley, 2014) -Softness/personalized has a large effect on comfort and friendliness (Nasar 2011) -Reduce stigma with a normal community setting (Connellan, 2013) -Lounge like context was more comfortable than a clinical or office-like context (Sanders, 2018) -“Furthermore, social connections, even those that are categorized as “familiar strangers” have the potential to increase one’s sense of community and reduce feelings of loneliness” (Snethen, 2020) -”Places with opportunities for being, doing, becoming and belonging are those that facilitate recovery” (Snethen, 2020, Doroud, 2018) -Use of a galleria space made patients feel like they had increased autonomy and were able to make their own decisions (Ahern, 2016) -The degree of privacy is important to those in a waiting room because of stigma (Noble, 2021)

-Visual or physical access to nature (Shepley, 2014) -Soothing artwork that patients can relate to Shepley (Shepley, 2014) -Multiple view of nature, incorporate sunlight and fresh air (Shepley, 2014) -Sensory modulation includes: massage chairs, weighted blankets, weighted lap pads, soft blankets, aromatherapy, music, stress balls and fidget tools (Andersen) -Access to gardens, nature window views reduce stress (Ulrich, 2018) -Physical access to a garden helps to reduce stress-natural styles with vegetation and flower (Ulrich, 2018) -Also offers a space for privacy or socialization -Providing positive distractions like art helped to reduce patient anxiety and reduce length of stay (Andrade, 2015) -Nature images resulted in lower blood pressure and cortisol levels (Mochizuki-Kawai, 2020)

Table 8. Problems and Goals

5.2 Literature by Space Entry Waiting Room

Counseling Room

-Using natural content in the entry was seen as supportive by therapists (Liddicoat, 2020) -”Entry experiences are enhanced by design aspects which foster privacy and seclusion”(Liddicoat, 2020)

-Highly rated waiting rooms were welcoming, comfortable, spacious, had lots of seating (Noble, 2021) -use of nature in waiting area (artificial and natural) could reduce user anxiety and improve satisfaction (Beukeboom et al, 2012) -Important to have movable seating that allows patients choice and control (Liddicoat, 2020) -as well as flexible layouts -Sight lines should be managed so that users don’t feel like they are on display (Liddicoat, 2020) -Sensory modulation by visual distractions of art or views or richness of material use (Liddicoat, 2020) -Glass separation from staff made users feel scrutinized and controlled (Liddicoat, 2020) -Natural sounds, daylight, and a more colorful waiting room decrease patients’ physical symptoms of anxiety (Bazley et al., 2016). -Positive aspects were towards the variety in type and location of seating, increasing privacy and personal space (Noble, 2021) -Use furnishings that suggest high quality and softness/comfort (Noble, 2021) -A variety of decor that is natured themed, plants, nature artwork, aquariums-can act as positive distractions (Noble, 2021) -Softness, personalization and orderliness were the most important factors to patients and increased judgement of care and personal comfort (Devlin, 2014) -Rooms with less aesthetic appeal, poor organization and harsher light were rated less favorably (Kasmar, 1968) -DIm lighting was viewed as more pleasant and relaxing and the impressions of the interviewer were more positive and they disclosed more (Miwa, 2006) -Interviewer felt more positive under dim lighting (Miwa, 2006) -as softness/personalization and order improved, expected quality of care, comfortness, boldness and qualifications of the therapist improved (Nasar, 2011) -softness/personalized has a large effect on comfort and friendliness (Nasar, 2011)

Table 9. Literature by Space

5.2 Literature by Space Group Counseling Room Supportive Spaces

-Same as Counseling Room -Movable seating, increased choice and control (Ulrich, 2018)

”Smaller activity space creates stronger sense of community” (Shepley, 2014) -lounge like context was more comfortable than a clinical or office-like context (Sanders, 2018) - “Furthermore, social connections, even those that are categorized as “familiar strangers” have the potential to increase one’s sense of community and reduce feelings of loneliness” (Snethen, 2020) -”Places with opportunities for being, doing, becoming and belonging are those that facilitate recovery” (Snethen, 2020, Doroud, 2018) -Circulation that keeps users entering and users leaving from interaction and maintains privacy (Liddicoat, 2020) -Nature images resulted in lower blood pressure and cortisol levels (Mochizuki-Kawai, 2020)

Table 9. Literature by Space

5.3 Case Study Analysis

Table 10. Case Study Analysis

5.3 Case Study Analysis

5.4 WSU Counseling and Psychological Services Student Population as of 2016: 29,686

Figure 18. WSU Counseling and Psychological Services Room Analysis

5.5 IRB Approval From: To: Subject: Date: Importance:

irb@wsu.edu Jupina, Rachel Certificate of Exemption, IRB #19011-002, "University Students Perceptions of Campus Counseling Centers" Thursday, August 19, 2021 5:23:49 PM Low

8/19/2021 TO: Alana Pulay, Rachel Jupina and Minyoung Cerruti, FROM: Heather Brackett, Office of Research Assurances (3143) Based on the evaluation of the application and materials submitted for the study titled "University Students Perceptions of Campus Counseling Centers," (IRB # 19011), the WSU Human Research Protection Program (HRPP) has determined that the study satisfies the criteria for Exempt Research at: 45 CFR 46.104 (d) (2) (i) – Research involving survey, interview, focus group or educational testing (cognitive, diagnostic, aptitude, achievement) data that is collected anonymous or unlinked to subject identity. It is your ethical responsibility to ensure subjects are informed of the research and give consent to participate. Templates are available on our website for you to use. This study may be conducted according to the protocol described in the Application without further review or approval by the IRB. Studies certified as Exempt are not subject to continuing review, but will receive annual status check emails. It is important to note that certification of exemption is NOT approval by the IRB. Do not include the statement that the WSU IRB has reviewed and approved the study for human subject participation. Remove all statements of IRB Approval from study materials that will be disseminated to participants. This certification is valid only for the study protocol as it was submitted to the ORA. If any changes are made to the study protocol, you must submit the changes to the ORA for determination that the study remains Exempt before implementing the changes (The Amendment Request form is available online at http://www.irb.wsu.edu/forms.asp). Per ORSO's Guideline 8: "-All faculty, staff, professional, graduate, and undergraduate students involved in the design, conduct, oversight, or reporting of applicable creative activities, research, and scholarship are required to take RCR training, provided by Collaborative Institutional Training Initiative (CITI). -The faculty and/or Principal Investigator (PI) are responsible for ensuring that all employees and professional, graduate, and undergraduate students complete RCR training and other required training as outlined in this Guideline. The Office of Research will send out regular reminders Rev. January 2020 regarding required RCR training" https://research.wsu.edu/2019/03/28/responsible-conduct-of-research-rcr/ Exempt certification does NOT relieve the investigator from the responsibility of providing continuing attention to protection of human subjects participating in the study and adherence to ethical standards for research involving human participants.

5.6 Survey Questions Q1: Consent Form Q2: Are you a student at the Washington State University Pullman Campus? Yes No Q3: Are you 18 Years or older? Yes No Q4: What year are you in school? Freshman Sophomore Junior Senior 5th Year+ Q5: How do you identify? Male Female Non-Binary Decline to Answer Self-Identify Below 60

Q6: Do you know where the WSU Counseling Services is located on campus? No Yes Q7: Have you used WSU Counseling Services before? No Decline to Answer Yes Q8: Please rate the following factors on how they would impact your access/ usage of the WSU counseling center. Very Positive Influence 1

Positive Influence 2

No Influence 3

Negative influence 4

Very negative influence 5

Fear of Stigma

Lack of Time

Financial Concern Preference for selfmanagement Inconvenient Location Unpleasant physical environment/atmosphere

Table 11: Q8 Likert Scale

Survey Questions Q9: How important do you feel that the overall design of a counseling center is likely to influence your perception of the counseling center itself? Very Positive Influence

Positive Influence

No Influence

Negative Influence

Very Negative Influence

Q10, 13, 16, 19, 22, 25, 27, 31: Please answer the following questions about the [existing/new space] based upon your reaction to the image below. Please rate each of the following items on how they influence your perception of the space in terms of feelings of stress. Very Positive Influence 1

Positive Influence 2

Privacy

Artwork and/or Views of Nature

Amount of Seating Options Seating Arrangements 62

Table 12. Space Perception and Stress Likert Scale

No Influence 3

Negative influence 4

Very negative influence 5

Q11, 14, 17, 20, 23, 26, 29, 32: Please rate each of the following items on how they influence your perception of the space in terms of stigma. (Stigma is defined as feelings of judgment or discrimination based on a stereotype) Very Positive Influence 1

Positive Influence 2

No Influence 3

Negative influence 4

Very negative influence 5

Privacy

Artwork and/or Views of Nature

Amount of Seating Options Seating Arrangements Table 13. Space Perception and Stigma Likert Scale

Survey Questions Q12, 15, 18, 21, 24, 27, 30, 33: Please rate each of the following items on how they influence your perception of the space in terms of usage of the space. Very Positive Influence 1

Positive Influence 2

No Influence 3

Negative influence 4

Very negative influence 5

Privacy

Artwork and/or Views of Nature

Amount of Seating Options Seating Arrangements Table 14. Space Perception and Access Likert Scale

Q34: How important do you feel that the overall design of a counseling center is likely to influence your perception of the counseling center itself? Very Positive Influence

Positive Influence

No Influence

Negative Influence

Very Negative Influence

These are new spaces that do not exist in our current counseling center. We want to know how they may impact your experience. Please rate the following spaces on how they would impact your usage of a counseling center. No Importance

Slightly Important

Somewhat Important

Moderately Important

Very important

Meditation Rooms Multipurpose Rooms (for yoga classes, mindfulness classes, etc)

Gathering areas (casual seating areas, coffee shop, etc) Table 15. New Spaces and Usage

Q36: What is it about a counseling center design that would positively affect your experience in terms of stress and/or stigma? [Open Ended] Q37: What is it about the a counseling center design that would negatively affect your experience in terms of stress and stigma? [Open Ended] Q38: Where do you think the counseling center should be located? (click anywhere on map) 65

5.7 Appendix

Survey Results: Entry

Table 16: Entry T-test Results

Survey Results: Waiting Room

Table 17: Waiting Room T-test Results

5.7 Appendix

Survey Results: Counseling Room

Table 18: Counseling Room T-test Results

Survey Results: Group Counseling Room

Table 19: Group Counseling Room T-test Results

5.8 Qualitative Process Q36: Positive Effect

Table 20.1 Qualitative Process-Positive Effect

Welcoming/Inviting Cont.

Table 20.2 Qualitative Process-Positive Effect

5.8 Qualitative Process Q37: Negative Effect

Table 21.1 Qualitative Process-Negative Effect

Hospital Cont.

People Cont.

Participants Who Changed from Positive to Negative/No Influence

Table 21.3 Unique Before and Afters Table 21.2 Qualitative Process-Negative Effect