As part of my training in clinical psychology, I had to select an existing NHS service to evaluate. I chose to evaluate a walking group called “Walk to Wellbeing”, which was facilitated by occupational therapists within a community mental health team. I was particularly drawn to the group’s combined use of urban and green spaces, and whether service users responded differently when walking in these environments.

I was interested to discover that green spaces did not appear to be more beneficial than urban alternatives (as prior research and theory would typically suggest). Instead, urban and green space walks were found to provide different benefits, for different service users, and at different times.

This finding served as an important reminder that when we want to look at whether or not an environment is conducive to a particular outcome (e.g., nature connection), we can’t do this in isolation of the individualised human interaction with that environment. For example, two people may be wandering through a beautiful and remote nature reserve, whist not connecting with any of the surrounding wildlife, instead focused on the benefits of their social interaction. At the same time, another person may be walking the busy city streets and experience a connection with a single, resilient weed they spot growing in the concrete.

The full findings of this evaluation are currently under review for publication, but for now I wanted to share a very brief overview using the slides below (also see my slide notes below the slides).

Side notes:

Slide 1 – Title

• This was an evaluation of an occupational therapy (OT)-led walking group in a UK, NHS community mental health team (CMHT).
• The group was called ‘Walk to Wellbeing’ and had been running for 10 years without previously undergoing a formal evaluation. It was also felt to be at risk as similar groups had been cut from services for cost-saving purposes. This presentation intends to provide a brief account of a study into Walk to Wellbeing.

Slide 2 – Background

• Research has clearly demonstrated that getting outdoors is good for our physical, psychological and social health. Psycho-evolutionary theories, such as biophilia, also argue that early humans were immersed in the natural world for millions of years and a detachment from nature seen in modern humans is a source of psychological distress.
• Previous studies have shown walking groups are effective, but this research has mainly focussed on walking groups for the general public. The few studies that have explored walking groups within mental health services have only looked at immediate outcomes and not whether these outcome transfer to service users’ day-to-day lives in the longer term.
• ‘Walk to Wellbeing’ is an occupational therapy (OT)-led walking group situated within a community mental health team (CMHT). It runs throughout the year, with the service users and OTs meeting fortnightly in city centre location. The group (typically 8-10 members) decide among themselves on the day where to walk. The walk lasts between 1 and 2 hrs and is followed by a refreshments break. The location of walks includes natural environments (e.g., parks and countryside) and urban walks (e.g., city centre, shopping centres, museums). Given the wealth of previous research and theories suggesting green spaces are more therapeutic than urban spaces, one of the specific aims of the present study was to compare experiences of green vs. urban walks.
• In summary, the aims of this study were to evaluate the immediate outcomes of Walk to Wellbeing, explore whether these outcomes result in longer term transfer, and to compare green vs. urban walks.

Slide 3 – Methods

• The methods were guided by experiential pragmatism, a modern philosophical standpoint that favours using mixed-methods to explore multiple angles, as well as methods that are flexible to fit the setting/participants rather than fitting the participants to a method. The ‘experiential’ is about having some freedom to explore and adapt those methods as the evaluation progresses.
• The pre/post questionnaire comprised previously validated scales such as those measuring confidence in communication, anxiety, depression, self-esteem, physical health, and relationship with nature.
• Service users were invited to complete a written diary after each walk, which had three open-ended reflective questions about their experiences and outcomes.
• Interviews were 1-to-1 and semi-structured, both with the service users and the OT facilitators.
• The service users did not engage well with the quantitative measures, and so the study focused on the qualitative methods/data. 7 service users (5 male 2 female) competed diaries and interviews. This sample reflected the core group of service users who attended the walk most weeks.
• Additional qualitative data was collected from feedback forms received from previous groups during the past 10 years that Walk to Wellbeing had been operating.
• Data was transcribed and entered into Nvivo.
• Themes comprised patterns of shared meaning and co-authors were consulted for collaborative reflexivity.

Slide 4 – Results

• THEME 1. INTERRELATED OUTCOMES: Immediate outcomes were interrelated, and included biological (e.g., physical fitness), psychological (e.g., improved mood, decreased anxiety), sociological (e.g., greater sense of belonging, integration into the community), and ecological (e.g., connectivity with the natural world).
• THEME 2. NOT ALL ABOUT NATURE: Nature walks were not found to be more beneficial. Instead, green and urban spaces provided different benefits, for different people, at different times. Service users appreciated variety from their norms and exploring new places, regardless of whether they were green or urban. Some of those who lived in the city centre appreciated getting out into green spaces. Others who lived outside the city centre sometimes found the city centre anxiety provoking and would avoid it even when they needed to make necessary trips, so benefitted from increased confidence gained from the city walks. Green walks appeared effective in reducing anxiety, and the urban walks were effective for developing social skills and community engagement. The Model of Human Occupation (MOHO), which underpinned the OT’s facilitation, explained how the benefits of the group depend on the unique way an individual interacts with the environment they are in.  Focusing on the benefits of an environment in isolation from the person who is to be interacting with it is not always helpful.
• THEME 3. NON-DIRECTIVE TRANSFER: Transfer of outcomes to day-to-day lives was evident in SOME service users (e.g., helping them to have the confidence to get jobs, engage in other social groups outside the walking group etc). However, others were unable to recognise opportunities to transfer outcomes they were experiencing within the group. ‘Non-directive’ was the term used to describe how the facilitators didn’t directly support this transfer process (e.g., they didn’t use goal setting, guided reflections, prompting etc), if transfer happened it happened, if it didn’t it didn’t.
• THEME 4. UNDERUTILISED RESOURCE: It was felt that the group should be offered to more service users (e.g., having multiple or larger groups) and more diverse client groups (e.g., most of those in the group had been referred via OT, even though referrals were accepted from other professions within the CMHT).  It was also felt that Walk to Wellbeing could be more collaborative within the multidisciplinary team; for example, it could be cofacilitated with psychologists and community psychiatric nurses.

Slide 5 – Discussion

• The outcomes of the walking group fit well with the biopsychsocialmodel. The model on Slide 5 was the biopsychosocial model as it was first introduced by George L. Engel, the American psychiatrist who first introduced the biopsychosocial model in 1977. Along with the bio, psycho and social factors, this original model also includes the biosphere (which was described as a person’s connection to the natural world), positioned as the broadest system where disruption can also cause distress. But as the model was adopted by various professions, this part of it has at times got lost in translation. This made me think about a psychologist’s typical practice and how, although we pride ourselves on being informed by this model, the areas we influence can at times be more limited in practice.