The slides below were presented at the the British Psychological Society’s (BPS) Division of Clinical Psychology Annual Conference (DCP, January 2020).
To view the BPS press release on this presentation click on the image below:
Background/Objectives: The ever increasing urbanisation and humans’ disconnection from nature is a global challenge, particularly given the therapeutic properties of time spent in natural environments. In response, mental health therapists have begun to harness nature’s restorative capacity by challenging convention and offering therapy outdoors. This presentation comprises a metasynthesis of experiences from those embarking on this novel adventure, with the aim of establishing a much needed framework for best practice.
Design: A mixed-method, thematic synthesis was used according to PRISMA and ENTREQ guidelines.
Method: Systematic searches revealed 38 articles, published from 1994 to 2019, and comprising 322 therapists and 163 patients. Therapists comprised clinical psychologists, counselling psychologists, counsellors, and psychodynamic psychotherapists. Articles underwent critical appraisal prior to data extraction and the meta synthesis was conducted using Nvivo.
Results: A framework for outdoor therapy is presented, comprising higher and lower level themes. The outdoor context ranged in intensity from sitting or walking in urban parks and woodland to remote wilderness. The outdoors provided either a passive backdrop to therapy or was more actively incorporated through behavioural analysis, relationship building, metaphor, narrative therapy, role play, modelling, and stabilisation. Practical, therapeutic, and organisational issues raised by this approach were mitigated through assessment, informed consent, process contracting, and awareness of professional competency. Therapy was subsequently enriched by added mutuality, freedom of expression, mind-body holism, interconnectivity, and therapist well-being.
Conclusions: Theoretical support for nature-based therapy is provided and the question raised as to whether therapy in natural spaces should become a more mainstream treatment option.
The presentation notes for each slide are provided below, including some of the reactions on social media.
NB: actual presentation duration – 20 mins
Slide 1 – Title
- Hello, I’m Sam Cooley. I’m currently a 2nd year trainee clinical psychologist at the University of Leicester. I also have a research background in sport and exercise psychology (which often involves working outdoors!). So the topic of ‘outdoor talking therapy’, for me, is a coming together of these two fields.
Slide 2 – Overview
- To present a systematic review of outdoor therapy.
Slide 3 – Conventional talking therapy
- It’s probably fair to say that the ‘talking cure’, as it was termed when talking therapy was first introduced, is traditionally an indoor encounter.
- But studies suggest that service commissioners and managers don’t always value what that indoor space looks like, which can sometimes be four white and windowless walls.
- Contact outside this indoor space has traditionally been considered a boundary violation, unless of course the work is taken outdoors for a specific behavioural/exposure type intervention.
Slide 4 – Theories
- So why take therapy outdoors? Theories from evolutionary psychology, such as the Biophilia Hypothesis, argue that early humans were immersed in the natural world for millions of years and that a detachment from nature seen in modern humans is a source of psychological distress.
- This idea is also supported by the bio-psycho-social model and ecological systems theory, where the natural world around us is one of the broadest systems of influence that we function in. We are living cells within this broader ecosystem. What we do to this outer world impacts upon our inner worlds in a reciprocal relationship.
Slide 5 – Quote
- An old quote from the founder of ecopsychology, described how conventional therapies focus on our more immediate systems, such as person and person, person and family, person and society. Outdoor therapy doesn’t neglect these areas but has an additional focus of connecting a person with the natural environment.
Slide 6 – Nature restoration – Evidence
- A range of previous systematic reviews clearly demonstrate that exposure to nature results in psychological, physiological, and social benefits.
- There is now even a push for public health guidelines, similar to that of physical activity, recommending a minim amount of nature exposure each week.
Slide 7 – Early clinical evidence
- Less research has been directed specifically at therapists and other practitioners who are using talking therapy outdoors.
- There are no previous reviews but there is qualitative evidence to suggest outdoor talking therapy is at least as effect as indoors, if not more effective for certain individuals.
- Currently there are no guidelines from NICE, the NHS, CORE training curriculums, BPS etc on how to go about taking talking therapy outdoors.
Slide 8 – Review aim
- With the hope of establishing a framework of best practice.
Slide 9 – Inclusion criteria
- All article types and professional practice papers, which explore client and practitioner experiences of outdoor talking therapy.
- Talking therapy is used to support mental health difficulties, neurological impairment, forensic rehabilitation, or physical health.
Slide 10 – Method Cont.
- A range of bibliographic databases were searched.
- Had to cast the net wide on the variety of search terms that may be used to describe outdoor talking therapy.
Slide 11 – Selection process
- Over 1200 articles were reduced to 38.
- The most common reasons for rejection were the outdoors being used therapeutically but in the absence of talking therapy (e.g., walking groups, outward bound experiences, horticultural programmes etc), and/or that did not involve talking therapy led by a qualified therapist.
Slide 12 – Results
Slide 13 – Article characteristics
- Most were professional practice articles with clinical case examples, and the rest, bar 2, were qualitative studies.
- They included 322 practitioners, slight majority female.
- Mostly psychotherapists and counsellors, 16% of papers featured clinical psychologists, and there were a small number of family therapists and clinical social workers.
- Only a small proportion of practitioners were located in a public health service.
- 163 clients, slight majority male.
- 45% of articles focused on using outdoor therapy with general clinical populations, rather than specifying a particular sub-group of clients it was appropriate for.
- Mostly individual and group therapy with some family and couple work.
Slide 14 – The framework
- The review resulted in a very broad and rich data set, that were organised into this framework of outdoor talking therapy.
- I only have time in this presentation to give a flavour of some of these themes but I will give the details at the end for the upcoming journal article if anyone wants to explore it further.
Slide 15 – Practitioner characteristics
- The practitioner characteristics, as you might expect, included those with a personal affiliation with nature – e.g., a passion for nature, a comfort with being in nature, and belief in its restorative capacity.
- They also used a flexible, integrative modality, adapting and being creative with conventional therapy models, whilst using a person cantered approach.
- They also had the professional confidence to go against the grain, and work in an environment that sometimes felt exposing and one which they hadn’t typically been trained to work in.
Slide 16 – Client characteristics
- Clients also reported having an attraction to natural spaces, such as already experiencing personal moments of healing, or from an attachment perspective having had fond childhood interactions with nature.
- Clients also often reported a discomfort with conventional indoor therapy, such as a perceived formality/pressure of the indoor setting, the ‘clinical’ feel of it, feeling trapped, or that it was a poor fit with their stage of development.
Slide 17 – The natural space
- The physical interaction with nature varied from a low to high intensity interaction.
- Low intensity: walking and sitting in areas of natural beauty, or nearby nature such as parks or outside the therapy room, low intensity was usually 1-to-1, and typically lasted the usual therapy hour.
- Moderate intensity: A more hands on interaction with nature such as through gardening, hiking, outdoor pursuits, which lasted several hours to a day.
- High intensity: Typically groups embarking on wilderness trips, where they are living in nature for several days or weeks, often led by an outdoor professional, and whilst talking part in intermittent talking therapy (group and individual).
Slide 18 – Therapy approach
- The talking therapy approach itself ranged from a passive to active incorporation of nature into what the client and therapist did/spoke about.
- For example, at the passive end of the scale, the talking therapy was the same as if it was indoors, with little or no reference made to nature and/or the environment they were in.
- Moving further along the continuum, the natural environment was incorporated into the therapy such as through the use of live nature-based metaphors and stabilisation/mindfulness exercises.
- The more active use of nature included the practitioner psychoanalysing clients whilst they were engaged in an outdoor activity, using outdoor activities to build relationships between people and nature, role play, behavioural modelling, and using experiences and accomplishments in nature to challenge ways of thinking and build new narratives.
Slide 19 – Potential issues
- Practical issues included the weather and terrain, physical safety, and problems accessing natural spaces if the therapy room was in an urban environment, or when outside being unable to access resources indoors.
- Therapeutic issues included the unpredictability of the natural world such as not always knowing how a person may react to an experience, being distracted from the focus of the talking therapy itself, and difficulties maintaining confidentiality in outdoor spaces that were open to the public.
- Organisational issues centred around services predominantly adopting a more clinical, biomedical approach that wasn’t typically inline with outdoor therapy, and practitioners therefore experiencing a lack of guidance and support from within their profession.
Slide 20 – Potential solutions
- Some of the potential solutions to those issues were firstly to incorporate nature into the assessment and formulation (i.e,. ‘does the client want to work outdoors and why?’, ‘is it physically and psychologically safe for this work to be taken outdoors?’, ‘what additional benefits would the outdoors provide?’, ‘how does the outdoors fit with the client’s recovery goals?’, ‘is the outdoors appropriate for what we have planned?). In this way, deciding whether outdoor therapy was suitable was little different to how an integrative indoor practitioner would set about determining what type of therapy model to use with a particular client. (The resulting framework presented earlier is therefore recommended as a source of reflexivity for those considering whether and how best to combine nature and therapy, rather than providing set of causally related mechanisms). Assessing the clients’ physical suitability was sometimes done through the use of health questionnaires or asking a client to check with their GP.
- Informed consent was truly INFORMED, as in the client and practitioner had a detailed prior discussion about the potential risks, what can and can’t be controlled (such as confidentiality/people walking past), what the client may wish to do in certain circumstances (such as how to respond if someone walked past that they knew), and indoor alternatives, before the client gave their consent.
- This consent then led to ‘process contracting’ which took the form of mini assessments during the course of therapy to address any issues as they arose within the dynamic environment, and to continually question whether the outdoor environment remained suitable.
- Although the outdoor environment is inherently unpredictable, predictability was introduced by practitioners when appropriate. This included sticking to fixed time frames and agendas, using prescribed routes or places to sit, using private outdoor spaces, or using a combination of indoor and outdoor work at different stages of the therapy.
- Practitioners also had to be aware of their professional limits such as by collaborating with outdoor professionals during the more adventurous activities, checking with their insurance providers, being creative with who they seek supervision from in addition to another talking therapist, and seeking additional training.
Slide 21 – Enrichment
- Some of the ways in which talking therapy was enriched through being outdoors included a greater sense of shared ownership of the therapy space and the power balance within the therapeutic relationship.
- A greater sense of freedom of expression (i.e., the outdoors was better able to support and contain client’s emotional distress), as well as provide a sense of escape/freedom from their day-to-day norms and ‘clinical diagnosis’.
- A more holistic integration of mind, body, and place.
- Interconnectedness with nature enabled clients to disconnect from technology and have a natural ‘therapy room’ they could return to themselves outside of therapy. This interconnectivity with nature also resulted in improved environmental and community behaviours.
- And finally improvements to therapist well-being were noted in terms of improved a) physical fitness; b) stress relief (i.e., feeling held and contained by nature, less “weighted down” after a difficult session, and feeling like nature became a third person in the therapeutic relationship that “shouldered” some of the responsibility of the encounter); and c) empowerment, which was felt through their creative application of therapy in a different environment from the therapy room.
Slide 22 – Discussion points
- Some of the findings that stood out for me included the improvements in environmental behaviour, which came through developing greater interconnectivity with nature, an important finding given the current climate crisis headlines.
- Given the high rates of practitioner burn out and absenteeism seen across services, discovering a form of therapy that has such profound benefits for practitioner wellbeing is a valuable thing.
- Outdoor therapy could also support the multimorbidity challenge faced in services, where clients are regularly found to have both mental and physical health difficulties that are made worse by sedentary lifestyles.
- It was a shame to discover numerous practitioners reporting that they felt forced into working privately because public health services such as the NHS are too rigid in their more medicalised and risk averse way of working. This is a potential area of concern as more holistic approaches such as outdoor therapy grow in popularity. If public health services remain static, more and more practitioners may feel forced out. This possibility could also mean that ethical and effective approaches to therapy outdoors become more exclusive to clients who can afford to access them privately.
- There were frequent calls for outdoor therapy approaches to be included within the curriculum for practitioner training courses. Unfortunately, some practitioners drawn to this way of working reported having to “make it up as they went along” without this training having been provided.
- Finally, my on-going research into talking therapy outdoors is now looking into the organisational culture within public health services and potential implementation strategies, including the further development of practitioner guidelines.
Slide 23 – Thank you
- Here are the details for the upcoming journal article that is currently under second review (this is a non-blind review process, hence my sharing).
- I would be really keen to hear from anyone interested in outdoor talking therapy or who is already engaging in this way of working!
If you would like to cite any content from the above presentation please use the following reference:
Cooley, S. J., Jones, C. R., Kurtz, A., & Robertson, N. (2020, January). ‘Into the wild’: Exploring the practice of talking therapy in natural outdoor spaces. Paper presented at the meeting of the British Psychological Society, Division of Clinical Psychology Annual Conference 2020, Solihull, UK.
Reactions from the online Twitter community
“Great to hear about @SamJoeCooley and his review of the potential benefits of therapy outdoors! Very much supported by the Holistic Faculty” (@HolisticFaculty; Holistic Faculty of the BPS Division of Clinical Psychology)
“Could be especially useful for those who are put off by the formality of a clinical setting.” (@Male_BPS; Male Psychology Section of the BPS)
“Fab research – I totally agree!! I used to walk & talk, through shopping centres, round the park, kick a ball during therapy sessions …. even where I work now, sit outside by our helipad, in the fresh air and talk. Must do more! #flexibletherapy” (Clinical Psychologist).
“I was working with someone about a year and really struggling, then the company moved to new premises and there was an immediate demonstrable difference in my ability to maintain psychological contact with that therapist. All because the room felt big enough to hold the crap. I wanted to share. I dont know much about why but the original space definitely felt too small, too exposing. I couldnt sit the most natural way for me, or feel physically held by the seats. It did halt my progress. NHS has similar issues with such a clinical setting” (ex-service user).
“As a trainee, outdoor therapy is something I’m really keen to learn more about. Anyone who uses the outdoors as part of their practice, I’d love to connect #TherapistsConnect” (Trainee Clinical Psychologist)
“Couldn’t agree more! I’ve observed the benefits professionally & personally, determined to adapt my approach accordingly – thank you for bringing the research together Sam” (Practitioner)
“While we shouldn’t choose our approach prior to meeting our client, there is absolutely no reason #therapy should be confined to four walls as @SamJoeCooley states in this piece. #Therapists should work in the framework they deliver best. If you’re best #outside, then go!” (Social Worker)