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Patient preferences for psychologicalcounsellors: Evidence of a similarityeffectAdrian Furnham a & Viren Swami ba Department of Psychology , University College London , UKb Division of Public Health, University of Liverpool , UKPublished online: 09 Jan 2009.

To cite this article: Adrian Furnham & Viren Swami (2008) Patient preferences for psychologicalcounsellors: Evidence of a similarity effect, Counselling Psychology Quarterly, 21:4, 361-370

To link to this article: http://dx.doi.org/10.1080/09515070802602146

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Counselling Psychology QuarterlyVol. 21, No. 4, December 2008, 361–370

RESEARCH REPORT

Patient preferences for psychological counsellors: Evidence of

a similarity effect

Adrian Furnhama and Viren Swamib*

aDepartment of Psychology, University College London; bDivision of Public Health,University of Liverpool, UK

(Received 14 October 2007; final version received 10 February 2008)

This study sought to examine the individual difference variables that affectpotential patient preferences for hypothetical psychological counsellors.A representative British sample of 257 adults indicated their preferences foreight psychological counsellors differentiated by sex, age, and training location.A five-way mixed analysis of variance (participant sex and age as within variables,and counsellor sex, age, ethnicity as between variables) indicated a significantmain effect for only counsellors’ ethnicity. There were also sex and ageinteractions showing evidence of a matching hypothesis: participants preferredcounsellors of their own sex and age. The implications of these findings areconsidered.

Keywords: patient preferences; counsellors; medical decision-making

Introduction

There currently exists an extensive literature of patient preferences for particular doctors(see Bernstein, Wade, & Hofman, 1987; Furnham, Petrides, & Temple, 2006; Furnham &Thompson, & McClelland, 2002). Specifically, various studies have looked at the factorsaffecting patient preferences (Braman & Gomez, 2004; Heaton & Marquez, 1990), patientsatisfaction (Derose, Hays, McCaffrey, & Baker, 2001), willingness to disclose informationand discuss symptoms (Young, 1979), and general aspects of the physician-patientrelationship (Elstad, 1994; Weisman & Teitlebaum, 1985).

For instance, it has been shown since the 1960s (Hopkins, 1967) and in various partsof the world (Ahmad, Hansa, Rawlins, & Stewart, 2002; Derose et al., 2001; Elstad, 1994;van den Brink-Muinen, de Bakker & Bensing, 1994) that for general health issues (Graffy,1990; Phillips & Brooks, 1998), and especially intimate symptoms (Nichols, 1987; van denBrink-Muinen et al., 1994; Waller, 1998; Young, 1979), female patients tend to show aclear preference for female practitioners. Some authors have suggested that thesepreferences may be based on the idea that female doctors spend more time with theirpatients in consultation, are more understanding, or tend to involve the patient more inmedical decisions (Elstad, 1994; Weisman & Teitlebaum, 1985).

Most studies have assumed that the issue of the practitioner’s sex is much moreimportant to women than to men. This assumption has received some empirical support(Derose et al., 2001; Young, 1979); however, in those cases where men have stated

*Corresponding author. Email: virenswami@hotmail.com

ISSN 0951–5070 print/ISSN 1469–3674 online

� 2008 Taylor & Francis

DOI: 10.1080/09515070802602146

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preferences, they tended to choose male doctors of all sorts (Kapphahn, Wilson, & Klein,1999). Overall, then, both male and female patients appear to show a preference for same-sex practitioners, possibly to reduce potential embarrassment in intimate examinations(Ahmad et al., 2002; Elstad, 1994; Heaton &Marquez, 1990; Kerssens, Bensing, & Abdela,1997; Plunkett, Kohli, & Milad, 2002; Waller, 1998).

Furthermore, same-sex practitioner preference is closely related to the medical problemand hence the particular speciality considered. One Dutch study (Kerssens et al., 1997)investigated patient preferences for practitioner sex across 13 different medical specialities,including surgeons, neurologists, and psychiatrists. Same-sex preferences were weak for‘instrumental health’ professionals (e.g., surgeons and anaesthetists), but stronger forspecialists who treat intimate and psychosocial health problems (e.g., gynaecologists).Interestingly, participants who expressed same-sex preferences cited the same reasons fortheir preference, irrespective of whether it was for a male or a female practitioner. That is,participants favoured male or female practitioners because they made them feel at ease,and were more approachable and open.

Doctor experience and age have also received research attention. Female patientpreferences for female doctors are known to be moderated by other variables, such asdoctor experience (Plunkett et al., 2002), patient age, and patient education (van denBrink-Muinen et al., 1994). Moreover, the available evidence suggests that most patientsvalue medical experience (Plunkett et al., 2002), which is confounded with practitioner age.The literature also suggests that patients (particularly women) tend to prefer doctors fromthe same ethnic background as their own and with whom they can communicate in theirnative language (e.g., Ahmad et al., 1989; Balarajan, Yuen, & Raleigh, 1989; Kapphahnet al., 1999). More recently, Ahmad et al. (2002) found differences between Canadianwomen of European descent and their counterparts of South Asian descent in terms oftheir preferences for family physicians. The authors suggested that, due to the collectivistnature of South Asian cultures, these women may have perceived their relationships withsame-sex practitioners as a source of psychosocial support and empowerment.

The present study extends the available literature by examining potential patientpreferences for psychological counsellors. This remains an interesting theoretical question,but also has immediate implications for the provision of counselling in particular areas andinstitutions (Netto, 2006). There currently exists a scattered literature from manycountries, and going back many years, on specific client correlates of preferences forpsychological counsellors. Overall it appears that clients prefer counsellors of their ownsex, age and ethnicity.

For instance, there is a fairly consistent literature focusing on schoolchildren,university students and adults, showing that all prefer counsellors of their own ethnicbackgrounds. This appears to be more strongly the case for Black, for example, ratherthan White Americans (Abbott, Tollefson, & McDermott, 1982; Haviland, Horswill,O’Connell, & Dynneson, 1983; Wolkon, Moriwaki, & Williams, 1973). More generally,this same-ethnicity preference has been established all over the world from Malaysia toNew Zealand (e.g., Atkinson, Wampold, Lowe, & Ahn, 1998; Littrell, Hashim, &Scheiding, 1989; Turner & Manthei, 1986; but see Ang & Yeo, 2004).

There is also some evidence that clients of all sorts prefer same-sex counsellors(Haviland et al., 1983; Littrell & Littrell, 1982). Although some studies show that clientsdiscount the importance of sex on questionnaire-based studies of preference (Manthei,Vitalo, & Ivey, 1982), there does appear to be a same-sex preference when more explicitmeasures of preference are used (Ang & Yeo, 2004; Littrell et al., 1989; Turner & Manthei,1986). Specifically, women and younger patients show stronger same-sex and age

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preferences than men or older clients (Cooper, 2006). However, a wide range of potentialconfounding variables may influence these preferences, such as the client’s age, experienceof counselling, and the presenting problem (cf. Furnham et al., 2006; Turner & Manthei,1986; Woodstock, Margavio, & Cotter, 2006).

The present study is an attempt to contribute to the literature on potential clientpreferences for psychological counsellors by examining in greater detail than in previousstudies preferences for counsellor sex, ethnicity and age (the latter being a variable that, toour knowledge, has received scant attention in the literature). Moreover, by utilising amixed design, in which participants were asked to rate their relative preference for eightcounsellors in a 2 (Sex)� 2 (Age)� 2 (Ethnicity) format, it was possible to examine theinteraction of these variables with each others, as well as with participant demographics,which is a novel aspect of the present study. Based on the above review of the literature, itwas predicted that: (H1) there would be a Counsellor sex�Participant sex interaction,indicating a sex-matched preference; (H2): there would be a Counsellor age�Participantage interaction, indicating a similarity or age-matching preferences, and; (H3) the Britishparticipants in the present study would choose British-trained counsellors.

Method

Participants

The participants of this study were 257 individuals (134 women, 123 men). Participants’demographic details are presented in Table 1. Participants’ age was categorized into twogroups (old versus young) by means of a median split (median¼ 42 years).

Table 1. Demographics and health-related descriptive statistics for the study sample (in percentagesunless otherwise stated).

ItemTotal

(n¼ 257)Women(n¼ 134)

Men(n¼ 123)

Age M 43.07 42.14 44.08SD 13.11 11.95 14.26

Ethnicity European Caucasian 88.7 87.3 90.2Asian 2.7 3.0 2.4Other 7.8 8.9 6.5Prefer not to say 0.8 0.7 0.8

Religion Christian 58.8 61.2 56.1None/atheist 30.7 26.1 35.8Other 7.0 8.9 4.9Not sure 3.5 3.7 3.3

Education No formal education 8.2 11.2 4.9GCSE/O-Levels 30.7 29.1 32.5A-Levels/equivalent 34.2 32.1 36.6Bachelors degree 21.4 24.6 17.9Masters/higher 5.4 3.0 8.1

Marital Single 18.3 15.7 21.1In a relationship 17.5 18.7 16.3Married 52.9 54.5 51.2Separated/divorced 10.5 10.4 10.6Widowed 0.8 0.7 0.8

(continued )

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Materials

Counsellor preference

Participants were provided with an online questionnaire (see Procedure below), in whichthey were asked to imagine that they had been referred by their general practitioner (GP)to a counsellor for an expert second opinion. The counsellor would provide personalassistance for more of a psychological, rather than a medical, problem. They were furtherinformed that their GP had given them the choice of one of eight counsellors.Subsequently, participants were presented with a list of 8 counsellors, varying alongthe dichotomised variables of sex, age, and location of training (e.g., ‘‘Dr James Cook,a 39-year-old man, who trained in London’’ or ‘‘Dr Ying Jinglei, a 54-year old woman,

Table 1. Continued.

ItemTotal

(n¼ 257)Women(n¼ 134)

Men(n¼ 123)

Income 5£15k 22.2 26.1 17.9£15k–22k 24.1 21.6 26.8£22k–30k 19.5 20.1 18.7£30k–40k 11.7 11.9 11.4£40k–50k 4.3 1.5 7.34£50k 4.7 3.7 5.7Unsure 6.2 5.2 7.3Prefer not to say 7.4 9.7 4.9

Are you a smoker? Regular smoker 24.9 26.9 22.8Occasional smoker 7.4 7.5 7.3Non-smoker 44.0 38.8 49.6Ex-smoker 23.7 26.9 20.3

Have you ever been seriously ill? Yes 37.0 35.1 39.0No 60.7 63.4 57.7Unsure 2.3 1.5 3.3

Do you have private healthinsurance?

Yes 19.1 18.7 19.5No 80.9 81.3 80.5

Approximately how many times inthe last year did you visit your GP?

None 12.8 7.5 18.71–5 times 67.3 67.9 66.76–10 times 10.9 14.2 7.310–15 times 4.7 6.0 3.3415 times 4.3 4.5 4.1

Compared with other people of yourown age and sex, would you sayyou lead a healthier lifestyle?

Yes 46.7 44.8 48.8No 33.5 34.3 32.5Unsure 19.8 20.9 18.7

Compared with other people of yourown age and sex, would you sayyou lead a riskier lifestyle?

Yes 24.9 23.1 26.8No 74.7 76.9 72.4Unsure 0.4 0.0 0.8

Have you ever consulted professionalhelp for a psychological problem?

Yes 21.8 25.4 17.9No 78.2 74.6 82.1

Religiosity M 2.86 3.05 2.66SD 1.83 1.87 1.77

Political orientation M 4.03 3.97 4.09SD 1.18 1.09 1.27

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who trained in Taipei’’). They were asked to rate each counsellor on a 10-point scale(1¼Low preference, 10¼High preference). Vignettes of this type have been shown tohave good psychometric properties when used in other areas of medical (Furnham et al.,2002) and social (Furnham & McClelland, 2004) decision-making.

Health-related descriptives and demographics

Participants answered seven questions about the state of their health and health-relatedbehaviours. They also reported their political orientation (1¼ Strongly right-wing,7¼ Strongly-left wing) and religiosity (1¼Not at all religious, 7¼Very religious).Finally, they provided their demographic details (see Table 1).

Procedure

Participants in the present study were recruited by an online marketing research companybased in Oxfordshire from a consumer panel company. These were individuals who hadopted to take part in online surveys, and were recruited from a variety of different sources(e.g., email, web sources, advertising). Participants were representative of the Britishpopulation in terms of age, sex, socioeconomic class and educational qualifications,although this sample may also be more aware of new media and technology comparedwith the general population.

Participants were invited to take part in the survey by email. The panel was managed toensure that respondents only receive a certain number of surveys per month. In addition,the subject matter of surveys is strictly managed. This ensures, firstly that the panel are notcompleting the surveys as ‘professional respondents’ (i.e., doing as many surveys aspossible to earn money), and secondly that the panel do not complete more than onesurvey on the same topic. Participants were offered ‘points’ that could be redeemed forstore credit in return for participating in the survey.

Results

Descriptive statistics

A series of one-way analyses of variance (ANOVAs) showed no significant differencesbetween women and men on age [F(1,256)¼ 1.41, p40.05], religiosity [F(1,256)¼ 3.00,p40.05] and political orientation [F(1,256)¼ 0.66, p40.05]. Mann-Whitney U testsshowed no significant sex differences on any of the demographic variables: ethnicity(z¼�0.74, p40.05), religion (z¼�0.54, p40.05), education (z¼�0.70, p40.05), maritalstatus (z¼�0.60, p40.05), income (z¼�0.89, p40.05). Finally, Mann-Whitney U testsshowed no significant sex differences on most of the health-related descriptives: smoker(z¼�0.14, p40.05), seriously ill (z¼�0.45, p40.05), insurance (z¼�0.17, p40.05),perception of healthy lifestyle (z¼�0.66, p40.05), perception of risky lifestyle (z¼�0.56,p40.05), and psychological consultation (z¼�1.45, p40.05). Women were more likelythan men to have had a higher number of GP visits in the past year (z¼�2.89, p50.05),which is consistent with the extant literature (see Idler, 2003).

Counsellor preference

A five-way split-plot mixed ANOVA was conducted, with the sex (male or female), age(young or middle-aged) and training location (Brittan or Asia) of the counsellor as the

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repeated measures factors, and participants’ sex (male or female) and age category (young

or old) as the between-subjects factors. The results of this analysis are reported in Table 2.

Results showed only one significant main effect, with participants preferring counsellors

trained in Britain over those trained in Asia (Britain M¼ 6.66, SD¼ 2.12; Asia M¼ 5.40,

SD¼ 2.30).There were a number of significant two-way interactions. First, counsellor sex

interacted with participant sex, such that women preferred female over male counsellors

[t(133)¼�4.86, p50.001], whereas men preferred male over female counsellors [t(122)¼

353, p50.05]. Second, there was a significant interaction of the counsellors’ age and sex,

Table 2. Five-way split-plot ANOVA results for counsellor preference.

Source F ratioa p-value �2p

Counsellor sex 3.08 0.08 0.01Counsellor sex�Participant sex 34.49 0.00 0.12Counsellor sex�Participant age 0.27 0.60 0.00Counsellor sex�Participant sex�Participant age 1.56 0.21 0.01Counsellor age 2.55 0.11 0.01Counsellor age�Participant sex 0.78 0.38 0.00Counsellor age�Participant age 5.12 0.03 0.02Counsellor age�Participant sex�Participant age 2.54 0.11 0.01Counsellor training location 72.22 0.00 0.22Counsellor training location�Participant sex 0.06 0.80 0.00Counsellor training location�Participant age 3.62 0.06 0.01Counsellor training location�Participant

sex�Participant age6.11 0.01 0.02

Counsellor sex�Counsellor age 6.42 0.01 0.03Counsellor sex�Counsellor age�Participant sex 1.89 0.17 0.01Counsellor sex�Counsellor age�Participant age 0.29 0.59 0.00Counsellor sex�Counsellor age�Participant sex x

Participant age0.93 0.34 0.00

Counsellor sex�Counsellor training location 12.34 0.00 0.05Counsellor sex�Counsellor training

location�Participant sex0.90 0.35 0.00

Counsellor sex�Counsellor traininglocation�Participant age

0.02 0.90 0.00

Counsellor sex�Counsellor traininglocation�Participant sex�Participant sex

2.78 0.10 0.01

Counsellor age�Counsellor training location 7.73 0.01 0.03Counsellor age�Counsellor training

location�Participant sex1.18 0.28 0.01

Counsellor age�Counsellor traininglocation�Participant age

1.28 0.26 0.01

Counsellor age�Counsellor traininglocation�Participant sex�Participant age

1.50 0.22 0.01

Counsellor sex�Counsellor age�Counsellor traininglocation

0.25 0.61 0.00

Counsellor sex�Counsellor age�Counsellor traininglocation�Participant sex

3.09 0.08 0.01

Counsellor sex�Counsellor age�Counsellor traininglocation�Participant age

0.55 0.46 0.00

Counsellor sex�Counsellor age�Counsellor traininglocation�Participant sex�Participant age

4.68 0.02 0.02

adf¼ (1,255) in all cases.

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where older male counsellors were preferred over younger male counsellors [t(256)¼ 2.60,p50.05]; there was no difference in preference for female counsellors as a function of age[t(256)¼ 0.42, p40.05]. There was also a significant interaction of the counsellor’s sex andlocation of training: when training had taken place in Britain, female counsellors werepreferred over male counsellors [t(256)¼�3.65, p50.001]; there was no difference in thepreference for the sex counsellors when training had taken place in [t(256)¼ 0.47, p40.05].The counsellors’ age also interacted with participants’ age such that older participantspreferred older counsellors [t(127)¼�6.49, p50.001], whereas younger participantspreferred younger counsellors [t(128)¼�5.76, p50.001]. Finally, the counsellor’s ageinteracted with training location, such that for Asian-trained counsellors, olderpractitioners were preferred over younger practitioners [t(256)¼ 3.27, p50.05]. Therewas no corresponding difference in preferences for British-trained counsellors[t(256)¼�0.23, p40.05].

Predictors of preferences

To investigate predictors of preferences for counsellors, we first calculated an overallpreference score by averaging the eight counsellor ratings for each participant. We thencorrelated this overall rating with participants’ demographic and health-related descriptivestatistics. Of all the items in Table 1, only participants’ self-perceptions of healthy lifestylein relation to others was significantly correlated with overall counsellor preference(r¼�0.17, p50.05). We, therefore, offered this item as candidate variable to linearregression model. The overall regression was significant [F(2,256)¼ 7.74, p50.05], withself-perceptions of healthy lifestyle explaining 3% of the variance (�¼�0.17, t¼�2.78,p50.05).

Discussion

The results of the present study showed support for the three hypotheses described at thestart of this experiment. First, there was strong evidence for a similarity, or matching,effect. Specifically, we found a strong interaction between counsellor sex and participantsex, indicating a sex-matched preference. There was also a counsellor age by participantage interaction, again in the direction of age-matched preferences. Finally, the presentresults showed a significant main effect for only one counsellor variable (ethnicity). Theseresults are discussed in greater detail below.

In terms of main effects, the finding that only counsellor ethnicity showed a significanteffect was no doubt due to the fact that the large majority of participants were Britons ofCaucasian descent. These participants likely showed a preference for British (or moreaccurately, perceived British) counsellors who were locally-trained. That is, while thepresent did not explicitly mention ethnicity as a factor in participants’ decisions, it appearsthat participant infer some knowledge about the ethnicity of counsellors based on theirname and training location. Indeed, pilot testing with this and similar questionnaires (e.g.,Furnham et al., 2006) indicated that all participants who read the questionnaire assumedthe locally-trained practitioners were British, English-speaking counsellors, while theircounterparts were of Asian ethnicity and training.

In this sense, the third hypothesis (H3) of this study was confirmed. That is,participants appear to have a strong preference for counsellors of their own ethnicbackground. This probably represents not a form of overt racism, but rather a belief that

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individuals of the same ethnic background may be in a better position to understand and

empathize with one another (Hall, Guterman, Lee, & Little, 2002). For instance, the belief

that a counsellor speaks the same language, or comes from the same cultural background,

as one’s self may enhance the preference for a counsellor who shares the same background

as the self. Indeed, in the present study, the counsellor’s ethnicity showed the largest partial

eta squared value, suggesting that it was the strongest factor influencing patient

preferences of those manipulated here.Neither the age nor sex of the hypothetical counsellor showed significant main effects.

Thus, female counsellors were not preferred over males, or the middle-aged over the

young. However, as predicted and in accordance with H1 and H2, there was evidence of a

similarity, or matching, effect. Specifically, participants appeared to show a preference for

counsellors who were of the same sex and age as themselves. However, it should be noted

that the partial eta squared value was considerably larger for the sex preference compared

with the age preference, suggesting that the former may be a stronger predictor of

participants’ preferences than the latter.Certainly, the similarity preference in terms of sex is consistent with the available

literature, both in the medical (e.g., Ahmad et al., 2002; Derose et al., 2001; Elstad, 1994;

Furnham et al., 2006; Kerssens et al., 1997; Phillips, & Brooks, 1998; van den Brink-

Muinen et al., 1994; Waller, 1998; Young, 1979) and counsellor (Ang & Yeo, 2004;

Cooper, 2006; Littrell et al., 1989; Turner & Manthei, 1986) literatures. It should be noted

that, in the present study, there was a slight numerical trend (not significant but

discernible) to prefer female practitioners, but it was only in the interaction with

participants’ sex that the effect became significant. Further, while both sexes showed a

same-sex preference, this was more noticeable among female participants, who appeared

to differentiate more strongly and more consistently.There was a similar, but less powerful, similarity effect for age, insofar as younger

participants preferred younger counsellors, and older participants preferred older

counsellors. Again, this is consistent with the available literature on counsellor preferences

(e.g., Cooper, 2006). However, it should be highlighted that, in the present study, both the

counsellors’ and participants’ ages were rather crudely divided into two age groups (young

versus old). Age is a continuous variable, and it may be desirable to observe the power of

age using more appropriate methodological designs. For now, this must remain the task

for future research.In terms of limitations, it is worth commenting on the fact that the present study only

manipulated three possible factors relating to counsellor demographics. In reality,

preferences for counsellors are no doubt influenced by a range of other factors, such as

the style or type of counselling on offer, the extent to which counsellors have been

recommended, availability, fees, physical attractiveness (Young, 1979) and counselling

style (Aruguete & Roberts, 2002). Furthermore, patient preferences for counsellors may

also be further influenced by the type of the presenting problem, or as a function of the

patient’s belief systems, social class or coping style. Future studies would do well to

incorporate some or all of these factors in their designs.A further limitation relates to the fact that our study was concerned with hypothetical,

rather than actual, patient preferences. Thus, we are not able to generalize these findings to

actual settings, although there is evidence to suggest that vignette-style studies such as this

are a good indicator of actual preferences (see Furnham & McClelland, 2004; Furnham

et al., 2002, 2006). It is possible that the preferences elicited in the present study do not

necessarily correspond with actual behaviour when forced to choose a counsellor. One way

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of extending the present study, therefore, would be a longitudinal design in which patientpreferences are elicited prior to their actually approaching counselling services.

In conclusion, the results of this study beg the bigger question of whether client-counsellor similarity has an effect on therapeutic outcome. It is difficult to conductappropriate studies looking at the efficacy of different therapeutic interventions, althoughthere is now an expanding literature in this field (Roth & Fonagy, 2004). Most of thesestudies have compared various types of therapy against one another, and few haveexamined whether practitioner and client factors (notably demographics) have a direct oreven placebo effect on outcomes. There remains much work to be done in these and relatedareas.

Declaration of interest: The authors report no conflicts of interest. The authors alone areresponsible for the content and writing of the paper.

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