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‘Into the Wild’: A meta-synthesis of talking therapy in natural outdoor spaces

March 2020
Clinical Psychology Review 77(1):101841

DOI:10.1016/j.cpr.2020.101841

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CC BY-NC-ND 4.0

Authors:

Sam J Cooley

University of Leicester

Noelle Robertson

University of Leicester

Time spent in natural outdoor spaces has physiological and psychological benefits, such as reduced stress responses and improved mood. Mental health practitioners have begun to harness nature's restorative capacity by challenging convention and taking talking therapies outdoors. This review synthesises the experiences of these practitioners and their clients, with the aim of establishing a framework for best practice. A thematic synthesis was used to provide a systematic and integrative exploration of multiple therapy professions. Articles (N = 38, published from 1994 to 2019) comprised 322 practitioners and 163 clients. A mixed-method meta-synthesis resulted in a framework of higher and lower level themes: the outdoor context for therapy ranged in intensity from sitting or walking in urban parks and woodland to remote wilderness expeditions. 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 were mitigated through assessment and formulation, informed consent, process contracting, enhancing predictability where possible, and awareness of professional competency. Therapy was subsequently enriched by added mutuality, freedom of expression, mind-body holism, interconnectedness with the natural world, and practitioner well-being. The question of whether therapy in natural spaces should become a mainstream treatment option is discussed.

Characteristics featured within the 38 articles.

…

PICOS statement.

…

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Contents lists available at ScienceDirect

Clinical Psychology Review

journal homepage: www.elsevier.com/locate/clinpsychrev

Review

‘Into the Wild’: A meta-synthesis of talking therapy in natural outdoor spaces

Sam J. Cooley

⁎

, Ceri R. Jones, Arabella Kurtz, Noelle Robertson

Department of Neuroscience, Psychology and Behaviour, Centre for Medicine, University of Leicester, UK

HIGHLIGHTS

•Psychologists, counsellors, and psychotherapists are increasingly using talking therapy outdoors.

•Individualised assessment and formulation is required to determine client suitability.

•Outdoor therapy beneﬁts from holism, mutuality, freedom, and interconnectivity.

•Most common in private practice due to barriers in organisational cultures.

•A framework is provided with key considerations for the outdoor therapy process.

ARTICLE INFO

Keywords:

Ecological systems

Biophilia hypothesis

Walking therapy

Nature exposure

Clinical psychology

Ecopsychology

ABSTRACT

Time spent in natural outdoor spaces has physiological and psychological beneﬁts, such as reduced stress re-

sponses and improved mood. Mental health practitioners have begun to harness nature's restorative capacity by

challenging convention and taking talking therapies outdoors. This review synthesises the experiences of these

practitioners and their clients, with the aim of establishing a framework for best practice. A thematic synthesis

was used to provide a systematic and integrative exploration of multiple therapy professions. Articles (N= 38,

published from 1994 to 2019) comprised 322 practitioners and 163 clients. A mixed-method meta-synthesis

resulted in a framework of higher and lower level themes. The outdoor context for therapy ranged in intensity

from sitting or walking in urban parks and woodland to remote wilderness expeditions. The outdoors provided

either a passive backdrop to therapy or was more actively incorporated through behavioural analysis, re-

lationship building, metaphor, narrative therapy, role play, modelling, and stabilisation. Practical, therapeutic,

and organisational issues were mitigated through assessment and formulation, informed consent, process con-

tracting, enhancing predictability where possible, and awareness of professional competency. Therapy was

subsequently enriched by added mutuality, freedom of expression, mind-body holism, interconnectedness with

the natural world, and practitioner well-being. The question of whether therapy in natural spaces should become

a more mainstream option for clients and practitioners is discussed.

Spending time in natural, outdoor spaces is said to nurture our

physical, emotional and spiritual existence, enabling individuals “to

sense, think, feel and act as interdependent beings, interconnected

within the whole community of life” (Conn, 1998, p.181). Theoretical

support for such anecdotes has been provided by the biophilia hy-

pothesis, which suggests humans have an innate and biological at-

traction to natural environments (Wilson, 1984). Grounded in evolu-

tionary psychology, the human mind and body has been shaped by

millions of years living in small communities immersed in nature

(Kellert, 1993). Even today, we are still thought to possess the positive

survival characteristics of being attracted to natural scenes that oﬀer

safety and nourishment (e.g., lush vegetation, running water, and high

ground) and have a healthy fear of scenes that pose a threat to survival

(e.g., cliﬀ edges, dangerous animals, and poisonous insects; Stevens &

Price, 2015). Ecopsychology is a growing movement that seeks to study

and further understand the relationship between humans and the nat-

ural world (Duncan, 2018). The basis of this movement is a belief that

our detachment from nature, caused by industrialisation and urbani-

sation, is a root cause of psychological distress (Roszak, 1992), with

some going as far as labelling the condition ‘nature deﬁcit disorder’

(Louv, 2010). This issue is particularly prevalent in cities, where green

space has become a prized commodity. These urban areas currently

house around 50% of the world's population, a ﬁgure that is predicted

to rise to more than 70% by 2050 due to further expansion (United

https://doi.org/10.1016/j.cpr.2020.101841

Received 4 July 2019; Received in revised form 14 January 2020; Accepted 22 February 2020

⁎

Corresponding author at: Clinical Psychology, Department of Neuroscience, Psychology and Behaviour, Centre for Medicine, University of Leicester, Lancaster

Road, Leicester LE1 7HA, UK.

E-mail address: sc747@leicester.ac.uk (S.J. Cooley).

Clinical Psychology Review 77 (2020) 101841

Available online 04 March 2020

(http://creativecommons.org/licenses/BY-NC-ND/4.0/).

Nations, 2014).

Early evidence for the restorative eﬀects of nature was provided in a

10-year study by Rodger Ulrich, who found hospital patients with

natural views from their bedside windows recovered from surgery

faster than those with urban views (Ulrich, 1984). This landmark

ﬁnding was later replicated (Verderber & Reuman, 1987), including in

prisons, where cell window views of nature were associated with low-

ered stress and physical illness (Moore, 1982;West, 1985). In other

experiments, adults who completed a cognitively demanding task felt

more relaxed after taking a walk through a wooded area compared to

urban areas (Hartig, Mang, & Evans, 1991), patients in hospital waiting

rooms reported feeling less stressed when seated next to plants

(Beukeboom, Langeveld, & Tanja-Dijkstra, 2012), and exposure to

sunlight (producing vitamin D) and negative air ions, which are more

prominent in outdoor spaces, are found to signiﬁcantly enhance mood

(Nakane, Asami, Yamada, & Ohira, 2002;Terman, Terman, & Ross,

1998).

These restorative eﬀects of nature are explained by

Bronfenbrenner's (1979) ecological systems theory. This theory for-

mulates how our individual characteristics interact with our sur-

rounding environment, which together determine our growth and de-

velopment. According to Bronfenbrenner's model, our surrounding

environment can be categorised into ﬁve interconnected systems that

range from our immediate environment such as our family, friends and

where we live (microsystems), to our broader social, cultural, political

and ecological environments (macrosystems). Fundamentally, humans

can be thought of as living cells in a reciprocal relationship with the

living body of Earth. What humans do to their outer world they also do

to their inner world (Roszak, 1992); for example, when we take the

time to plant trees and nurture our land, we are nurtured in return by

the fruit we harvest. This relationship was evidently more powerful in

early humans, who operated more directly with nature to ensure their

physical, social, and spiritual existence (Kellert, 1993).

A range of systematic reviews are further expanding the evidence-

base for nature restoration. For example, greenspace exposure is asso-

ciated with positive physiological eﬀects, such as decreased heart rate

and blood pressure (Twohig-Bennett & Jones, 2018); exercising in the

outdoors has more beneﬁcial eﬀects on revitalization, engagement,

tension, confusion, anger and depression, compared to exercising in-

doors (Coon et al., 2011); outdoor adventure activities are eﬀective

social and emotional interventions for disadvantaged youths and stu-

dents (Bowen & Neill, 2013;Cooley, Burns, & Cumming, 2015); outdoor

activities such as gardening and walking are eﬀective in improving

mental health and neurological conditions (Annerstedt & Währborg,

2011;Cipriani et al., 2017); and looking at nature has positive eﬀects

on mood, stress, concentration, and self-esteem (Bratman, Hamilton, &

Daily, 2012). Most recently, evidence now suggests that exposure to

nature of ≥120 min per week is related to optimal health and well-

being, initiating calls for public health guidelines similar to that of

physical activity (White et al., 2019).

These restorative eﬀects of nature exposure have given rise to var-

ious practices such as walking therapy (Revell & McLeod, 2016), hor-

ticultural therapy (Corazon, Stigsdotter, Moeller, & Rasmussen, 2012),

Shinrin-yoku (or ‘forest bathing’; Morita et al., 2007), and adventure

therapy (Bettmann & Jasperson, 2008). There is, however, an ongoing

debate around whether the term ‘therapy’ is applicable to all of these

practices. For example, Revell, Duncan, and Cooper (2014) distinguish

between nature exposure that occurs whenever we are outdoors (e.g.,

walking a nature trail or participating in a gardening group), and that

which occurs as part of a structured mental health therapy session (e.g.,

walking a nature trail or gardening whilst engaged in talking therapy

with a clinical psychologist). Both forms of exposure may be ther-

apeutic, and both may result in mental health beneﬁts; however, the

confusion lies in that both are often referred to under the same umbrella

terms, such as ‘nature therapy’ and ‘outdoor therapy’. Becker (2010)

therefore recommends a clearer distinction between what is

‘therapeutic’ and what is ‘therapy’. Although one approach is not con-

sidered greater or more valuable than the other, the term nature

therapy is recommended for describing experiences that are led by a

licenced practitioner, such as when talking therapy is used with a

natural environment providing the backdrop (Becker, 2010;Revell

et al., 2014). Alternative terms such as ‘therapeutic adventure’ and

‘nature experiences’ are suggested for other therapeutic uses of nature

that do not involve therapy (Becker, 2010).

Despite the use of nature restoration dating back to humans' early

existence, such as ancient Shaman healing rituals and the monastic,

medicinal gardens of the Middle Ages (Al-Krena, 1999), its incorpora-

tion into modern day therapy remains a relatively new area of practice.

Since ‘the talking cure’ was conceived by the likes of Freud (1900s),

Perls (1940s) and Beck (1960s), therapy has traditionally been a verbal,

cognitively-mediated activity, with the relationship between therapist

and patient at the core, and that almost exclusively takes place indoors

(Freud, 1973). Therapy only usually ventures outdoors when speciﬁc

behavioural interventions are required, such as when clients expose

themselves to phobias to desensitise fear responses and build coping

mechanisms (Antony & Swinson, 2000). With the exception of this type

of in vivo behavioural therapy, practitioners are beginning to question

why most other forms of therapy are typically conﬁned to four white

and sometimes windowless walls (Pearson & Wilson, 2012). Practi-

tioners who break with convention and take their work outdoors are

pioneering a signiﬁcant shift in paradigm, with non-essential contact

outside the therapy room previously frowned upon as a boundary

violation (Zur, 2001).

Recent studies of counsellors, clinical psychologists, and psy-

chotherapists highlight positive experiences of taking therapy outdoors.

Their anecdotal accounts and qualitative evidence suggest mental

health outcomes are at least as eﬀective, if not more eﬀective in certain

individuals, than those obtained indoors (e.g., Jordan, 2014;King &

McIntyre, 2018;McKinney, 2011;Revell & McLeod, 2016;Revell &

McLeod, 2017;Wiggins, 2018). Some clients and practitioners feel they

beneﬁt from a greater sense of shared ownership of a natural space

(Berger & McLeod, 2006) and that therapy outdoors oﬀers a more ex-

istential, humanistic approach that is sometimes lost in clinical settings

(Santostefano, 2008). It is also suggested that whilst a therapy room can

provide a safe, stable and containing space, it can also be anxiety

provoking for those clients who ﬁnd a more formal and clinical face-to-

face encounter intimidating (Jordan & Marshall, 2010). Natural spaces

have therefore been found to support those who may not ordinarily

engage with therapy (Scheinfeld, Rochlen, & Buser, 2011). Practitioners

also share how clients beneﬁt not only from the talking therapy, but

also from the restorative eﬀects of nature (Berger, 2009).

To progress this ﬁeld, this relatively small community of practi-

tioners have called for “a more comprehensive model of how to practice

therapy in outdoor natural spaces” (Jordan, 2015, p.30). Indeed, whilst

the previous aforementioned reviews have explored various physiolo-

gical, psychological and social outcomes resulting from nature exposure

in general, no previous review has focused speciﬁcally on nature ex-

posure used by mental health practitioners alongside talking therapy.

1. The present review

The present review aims to explore the experiences of practitioners

and clients who have practiced talking therapy in natural, outdoor

spaces, using a thematic synthesis (Thomas & Harden, 2008). Of par-

ticular interest are the approaches used and their appropriateness and

acceptability. From a social constructivist standpoint, the review seeks

to better understand the phenomena from multiple lenses and vantage

points, looking for similarities, diﬀerences, and relationships between

primary themes (Paterson, 2012). The resulting thematic synthesis is

expected to generate a level of understanding that is greater than the

sum of its parts (Thomas & Harden, 2008), which will lend itself to

establishing guidelines for best practice. With these aims in mind, a

S.J. Cooley, et al. Clinical Psychology Review 77 (2020) 101841

liberal approach is adopted towards the inclusion of various mental

health practitioners, each of whom are uniquely trained and practice

talking therapy outdoors from a variety of modalities. This approach is

particularly suited to clinical psychology, whose practice itself is si-

milarly integrative (Davey, Lake, & Whittington, 2015).

2. Method

The review methods were guided by the PRISMA (Moher, Liberati,

Tetzlaﬀ, & Altman, 2009) and ENTREQ (Tong, Flemming, McInnes,

Oliver, & Craig, 2012) frameworks, for enhancing transparency in

systematic reviews and the synthesis of qualitative research. The search

strategy was based upon the PICOS statement in Table 1 (Santos,

Pimenta, & Nobre, 2007).

3. Researcher backgrounds

The researcher backgrounds together comprised a variation of prior

experiences and attitudes towards nature therapy. The lead researcher

(SC) is a Chartered Psychologist with the British Psychological Society

(BPS), with a ﬁrst degree in sport and exercise sciences, a Ph.D. in

outdoor adventure education, and post-doc in youth development

through experiential learning and outdoor activities. He is currently

completing a doctorate in clinical psychology (DClinPsy) with a focus

on how talking therapy can be facilitated outside the therapy room.

CJ is a practicing occupational psychologist and lecturer in clinical

psychology, with an MSc and Ph.D. in occupational psychology. She has

research and applied expertise in organisational and individual resi-

lience, leadership, innovations, and the use of horticultural interven-

tions in primary care to improve clients' psychological wellbeing.

AK is a dual qualiﬁed clinical psychologist and psychoanalytic

psychotherapist who works as a senior clinical tutor, researcher, and

sees psychotherapy clients in private practice. Her expertise is in de-

mystifying therapy and the way we reﬂect on it, including relational

dynamics and submerged and unconscious meanings. AK does not

currently practice therapy outdoors.

NR is a professor of clinical and health psychology, programme

director of a clinical psychology doctorate training course, consultant

clinical psychologist in the NHS, and a fellow of the BPS. She has

particular expertise in the areas of physical health, implementing re-

search evidence, enhancing therapeutic alliance, and staﬀ distress and

resilience. NR does not currently practice therapy in an outdoor setting.

4. Search strategy

In December 2019, the following electronic bibliographic databases

were searched: The Allied and Complementary Medicine Database

(AMED), Cumulative Index of Nursing and Allied Health Literature

(CINAHL), GreenFILE, MEDLINE, PsycINFO, PubMed, and SCOPUS. A

prior scoping review identiﬁed the following search terms used to de-

scribe talking therapy that takes place in outdoor, natural environ-

ments: “Nature therapy” or “outdoor therapy” or “outside therapy” or

“nature guided therapy” or “nature assisted therapy” or “horticultural

therapy” or “garden therapy” or “walking therapy” or ecotherapy or

ecopsychology or “bush therapy” or “wilderness therapy” or “adventure

therapy” or “natural space therapy” or “adventure based counsel*” or

“outdoor behavioural healthcare”. A title, abstract, and keyword search

was conducted with no limits placed on the years searched. The search

was limited to peer-reviewed publications, dissertations/theses, and the

English language. In addition, a manual search was conducted of re-

levant books, reference lists, forward searches, and online journals.

4.1. Selection strategy

Article selection was guided by these inclusion criteria: (a) quali-

tative, quantitative, mixed-method, or professional practice articles,

which explore client or practitioner experiences of therapy in natural

outdoor spaces; (b) a focus on talking therapy used to support mental

health diﬃculties, neurological impairment, forensic rehabilitation, or

to provide psychological support in physical health settings; and (c)

professionals qualiﬁed to provide talking therapy and who are regu-

lated by a professional governing body. For simplicity, these various

professionals will be referred to collectively as ‘practitioners’ in re-

ference to the talking therapy aspect of their profession. Professional

practice papers (e.g., brief reports, commentaries, narratives, and re-

ﬂective accounts) were included as they are known to provide valuable

and candid insights that do not always feature within empirical re-

search (Paez, 2017).

The literature search and selection process is presented in the

PRISMA ﬂow diagram (Fig. 1;Moher et al., 2009). Common reasons for

rejection were the outdoors being used therapeutically in the absence of

talking therapy, interventions not being led by registered mental health

practitioners, non-clinical populations, therapy taking place indoors

with the outdoor component incorporated only as homework tasks, and

Table 1

PICOS statement.

PICOS Area As deﬁned in the present review

P Participants Certiﬁed mental health practitioners and clients

I Intervention/Exposure Talking therapy in a natural, outdoor spaces

C Comparison Experiences of the therapy process from multiple lenses

O Outcome/Endpoint A framework of considerations for taking therapy into natural outdoor spaces

S Study design No epistemological and methodological discrimination applied

Fig. 1. PRISMA ﬂow diagram.

S.J. Cooley, et al. Clinical Psychology Review 77 (2020) 101841

articles without suﬃcient detail to satisfy the aforementioned inclusion

criteria.

5. Critical appraisal

Articles were subject to critical appraisal using Kmet, Lee, and Cook

(2004) standard quality assessment criteria for evaluating primary re-

search papers from a variety of ﬁelds. The professional practice articles

were scored as qualitative, with non-applicable items relating to study

design and data analysis removed. Given the valuable contributions

that can be lost by ﬁltering out non-academically rigorous or ‘grey

literature’ (Paez, 2017), and the subjectivity and high likelihood of bias

inherent in critical appraisal tools (Katrak, Bialocerkowski, Massy-

Westropp, Kumar, & Grimmer, 2004;Kmet et al., 2004), critical ap-

praisal was used to provide reﬂexivity during theme generation, rather

than for exclusion purposes (The Joanna Briggs Institute, 2017).

6. Data extraction and thematic synthesis

As articles sometimes included additional data outside the scope of

a review, an extraction template was created to separate the data set

from the data corpus. This extraction template (see online supplemen-

tary material) was informed by the Template for Intervention,

Description, and Replication (TiDieR; Hoﬀmann et al., 2014), which

outlines 12 key areas to be addressed when reporting an intervention.

Once the data set had been extracted (27,507 words), it was entered

into NVIVO (version 12), for synthesis. This thematic synthesis (Thomas

& Harden, 2008) was led by author SC and involved an iterative and

reﬂexive process, whereby data from the original articles were assigned

descriptive codes line-by-line, and grouped into descriptive themes that

captured similarities, diﬀerences, and relationships that remained close

to themes within the original articles (Paterson, 2012;Thomas et al.,

2004). These descriptive themes were then further interpreted into

analytical themes that at times went beyond the primary data, gen-

erating additional constructs and explanations, whilst remaining

grounded in the primary data through constant comparison (Thomas &

Harden, 2008).

The synthesis of mixed-methods was informed by the Joanna Briggs

Institute's recommendations for mixed-methods synthesis, which in-

volved a separate synthesis of quantitative ﬁndings before pooling these

with the qualitative synthesis to result in one single thematic map

(Pearson, White, Bath-Hextall, et al., 2015). Within the resulting the-

matic map, the largest overarching themes were termed ﬁrst level

themes, which were heterogeneous to one another (Patton, 2015) and

typically reﬂected ‘domain summaries’ (e.g., ‘potential issues’, ‘poten-

tial solutions’, ‘client characteristics’ etc.; see Braun & Clarke, 2019).

Within these ﬁrst level themes, distinct yet related sub themes were

termed second level themes, which comprised patterns of shared

meaning. In some cases, these second level themes were further broken

down into third level themes (Patton, 2015). During theme develop-

ment, data and themes were presented and discussed with co-authors

(CJ, AK, and NR) for collaborative reﬂexivity (Braun & Clarke, 2019).

7. Results

7.1. Article characteristics

The 38 articles included were published between 1994 and 2019

(see the online supplementary materials for an article summary table).

The majority were professional practice papers (n= 22, 57.9%), over

half of which included clinical case examples (n= 13). Qualitative

studies made up 36.8% of articles (n= 14) and used interview and

open-ended survey methods guided by ethnographical, grounded

theory, interpretative phenomenological analytic, narrative, phenom-

enological, and realist methodologies. Only two articles (5.3%) used

quantitative methods (quasi-experimental and cross-sectional).

Quality appraisal scores ranged from 0.6 to the maximum score of 1

(M= 0.81; SD = 0.10). This range of scores would typically be con-

sidered acceptable for inclusion in a literature review according to the

ﬁndings of Kmet et al., 2004. Strengths were evident in clear and the-

oretically driven research questions, study design, and well supported

conclusions. Some studies (23.7%) scored partial marks for data col-

lection, mostly due to comprising a limited range of possible cases and

therefore constraining conceptual generalisation. Other articles

(26.3%) did not provide suﬃcient descriptions of approaches to data

collection and analysis to receive full scores. The majority (94.7%)

scored full or partial marks for their use of veriﬁcation procedures to

promote reﬂexivity, which were mostly prolonged engagement, trian-

gulation, and/or peer debrieﬁng. The main limitation was a lack of

reﬂective accounts regarding how personal characteristics and philo-

sophical stance may have inﬂuenced interpretations of data (provided

in full or in part by 42.1% of authors).

7.2. Sample characteristics

The 38 articles comprised 322 practitioners (58.4% female, 36.3%

male, 5.3% undisclosed) and 163 clients (57.7% male, 42.3% female).

The sample frequencies (Fig. 2) show that psychotherapists and coun-

sellors were the most frequent professions (featuring in 36.8% and

31.6% of articles, respectively), with an integrative modality most

popular (55.3% of articles). The most frequent settings were private

practice (44.7%) and educational/academic settings (29.0%), located in

the USA and UK (36.8% and 21.1%, respectively). The clients within

the articles comprised children/adolescents (29.0% of articles), adults

(29.0%), older adults (7.9%), or a non-speciﬁed/mixed age range

(44.7%), who were most commonly taking part in individual or group

therapy (50.0% and 44.7%, respectively). The outdoor activities were

mostly of low intensity (e.g., sitting and walking; 50.0%).

7.3. Themes

The ﬁrst and second level themes are depicted in Fig. 3. This fra-

mework for taking therapy into outdoor natural spaces begins with the

client and practitioner characteristics being mutually attuned to natural

spaces. The activity within the natural space can vary from a low to high

intensity interaction with nature, and the therapy approach can involve

either a passive or active incorporation of nature. The framework also

considers the potential issues resulting from the natural space, potential

solutions to these issues, and enrichment to therapy. Each of these themes

will be described in turn, with ﬁrst level themes sub-headed, second

level themes italicised, and third level themes described in text (see the

online supplementary material for a more detailed table of themes,

deﬁnitions, and data extracts). The example quotes provided from the

original articles are from clients, practitioners, and article authors.

7.4. Practitioner characteristics

Practitioners reported having a natural aﬃliation with nature, which

involved feeling connected and at peace in natural spaces, having a

“belief in the restorative and curative potential” (Revell & McLeod,

2017, p.276), and a “passion and excitement for what could be ac-

complished” (Wiggins, 2018, p.88). Incorporating therapy in natural

spaces also required a ﬂexible modality, with practitioners being creative

in adapting their conventional therapy model or integrating multiple

models. Practitioners felt they were engaging “in a therapeutic process

that is ﬂuid, emergent and integrative” (Revell & McLeod, 2017, p.276)

and that “trying to deﬁne one particular way of doing it would work

against its basic philosophy and concepts and kill the ﬁeld” (Berger,

2010, p.67).

Practitioners also reported a need for professional conﬁdence to

overcome the “sense of professional ‘diﬀerence’ due to oﬀering a

therapeutic activity that disrupts a commonly held perception of where

S.J. Cooley, et al. Clinical Psychology Review 77 (2020) 101841

Fig. 2. Characteristics featured within the 38 articles.

S.J. Cooley, et al. Clinical Psychology Review 77 (2020) 101841

and how therapy is oﬀered” (Revell & McLeod, 2017, p.277). Some

practitioners reported having to manage “feeling exposed, as though

aspects of my professional identity were stripped from me” (Jordan &

Marshall, 2010, p.356). Others described needing an ability to trust in

themselves and the therapy process “in an environment outside the one

in which I have (largely) been trained to work” (Tarrant, 2019, p.22).

7.5. Client characteristics

Given the wide heterogeneity across articles (e.g., age, gender,

setting, mental health presentation etc.; Fig. 2), suitability for outdoor

therapy could not be speciﬁed to any particular client group or pre-

senting problems. Instead, its incorporation was determined via more

person-centred considerations and formulation (Milton, 2009). These

considerations included clients demonstrating an attraction to natural

spaces, which stemmed from either feeling at ease in nature, excited by

it, or connected to nature, such as through positive childhood experi-

ences. Santostefano (2008) described this connection from an attach-

ment perspective:

… when aspects of nature and inanimate environments are avail-

able, the child can enter these environments to negotiate the tasks

life presents and continue to do so in the future. From this point of

view, I argue that healthy psychological development involves a

child, signiﬁcant others, nature, and inanimate environments all

growing together, beginning during the ﬁrst years of life, and be-

coming closely connected within the fabric of a child's matrix of

embodied life-metaphors. (p.525)

Often clients had already experienced “a personal moment of

healing that occurred for them in nature” (King & McIntyre, 2018,

p.122) and incorporating nature was found to add a degree of famil-

iarity into the therapy; for example, “most of us have walked with

friends [in natural environments] before” (McKinney, 2011, p.90).

Some clients also voiced a feeling of discomfort with conventional

therapy, which was typically driven by a perceived formality to the

encounter, feelings of anxiety, pressure and tension towards the face-to-

face interaction, or feeling trapped within an indoor space, which at

times caused them to ﬁnd it “very, very diﬃcult to sit in a room for any

period of time” (Jordan, 2014, p.369). Sometimes the natural en-

vironment was seen to better suit a client's presentation or develop-

mental stage, for example by oﬀering “children a less demanding en-

vironment, thus decreasing the pressure for them to perform verbally”

(Portrie-Bethke, Hill, & Bethke, 2009, p.325). Others felt the indoors

was lacking a level of excitement needed for them to engage (e.g.,

“there is no way in hell that I will sit in a [therapy room] and be bored

to death! I am too restless to sit around like that” Fernee, Mesel,

Andersen, & Gabrielsen, 2019, p.1372).

Fig. 3. A framework for talking therapy in outdoor natural spaces.

S.J. Cooley, et al. Clinical Psychology Review 77 (2020) 101841

7.6. Natural space

During outdoor therapy, the relationship between person and nature

varied from a low to high intensity of physical interaction, duration of

exposure, and interdependence. Low intensity interactions included sit-

ting, walking, and passive sensory experiences in the outdoors (e.g.,

Corazon et al., 2012;Corazon, Stigsdotter, Jensen, & Nilsson, 2010).

Sometimes these interactions were in areas of natural beauty, such as

lakes, mountains and coastal locations (e.g., Revell & McLeod, 2016),

and other times they comprised ‘nearby nature’ such as sitting outside

the back of a therapy room, or walking in local parks and on footpaths

(e.g., McKinney, 2011). These low intensity interactions were more

common in 1-to-1 therapy, with a duration similar to that of “the tra-

ditional therapy hour” (Jordan & Marshall, 2010, p.347) or “between

one and two hours in length” (Revell & McLeod, 2016, p.37). At times,

clients would have the autonomy to locate their own space:

This culminated in her wanting us to take a completely diﬀerent

route and explore a nearby unknown area. Interestingly, this latter

route and sitting space became for both of us, a more a truly co-

created place [sic], a mutually created physical container for the

therapy.

(Jordan & Marshall, 2010, p.351)

In other articles, clients' physical interactions and interdependence

with nature were of moderate intensity, such as gardening, problem-

solving (e.g., crossing a river and rope courses), constructing dens and

shelters out of natural materials, and outdoor pursuits (e.g., hiking,

climbing, and paddle sports; e.g., Hartford, 2011). In these interactions,

the time spent in nature was typically longer, such as a few hours to a

day, and clients would more often take part in groups (e.g., Corazon

et al., 2010). The high intensity end of the scale typically comprised one-

oﬀ wilderness expeditions in remote locations, where groups would

build shelters and live outdoors for days or weeks and engage in in-

termittent group and individual therapy (e.g., Scheinfeld et al., 2011).

In the majority of cases, there was ﬂexibility to move up and down

the continuum between low and moderate intensity activities de-

pending on perceived suitability (e.g., Adevi, Uvnäs-Moberg, & Grahn,

2018), yet for many of the higher intensity interactions, the experience

was inherently more predetermined given the more adventurous and

immersive nature of expeditions (e.g., Tucker, Widmer, Faddis,

Randolph, & Gass, 2016). Occasionally, some practitioners reported

pushing the intensity of the interaction with nature to just outside the

comfort zone of the client, “to appropriately enhance treatment by

fostering the development of eustress (i.e., the positive use of stress) as

a beneﬁcial element in the therapeutic experience” (DeMille &

Montgomery, 2016, p.4). In contrast, other practitioners reported a

need to ensure the intensity remained within the client's (and practi-

tioner's) comfort levels, so as not to be distracted from the talking

therapy itself (e.g., McBride & Korell, 2005).

7.7. Therapy approach

The degree to which nature was incorporated into the talking

therapy also varied. When nature was incorporated passively, the

talking therapy was little diﬀerent to that of conventional indoor

therapy, with the natural environment providing a passive backdrop

(e.g., “traditional counseling but the only thing diﬀerent is that we will

be walking instead of sitting in an oﬃce.” McKinney, 2011, p.88).

When nature was used more actively, it was incorporated as a third

person in the therapy, using a range of approaches some of which are

discussed below. In many cases, practitioners switched between active

and passive by shifting “attention from the person-to-person (practi-

tioner-client) relationship to the client-nature relationship, remaining

the mediator between them.” (Berger & McLeod, 2006, p.89); for ex-

ample:

The therapist may take a central position, working directly with the

client and relating to nature as a backdrop or tool provider. The

therapist may also take a quieter role, remaining in the background,

allowing the client to work directly with nature while the therapist

acts as a witness, container, and mediator.

(Berger & McLeod, 2006, pp.87–88)

Some of the more active approaches included using nature for sta-

bilisation. During times of distress, nature supported clients to feel safe,

contained, and grounded in the present moment. For example, this was

achieved by taking “short walks, to participate in simple sensory sti-

mulation activities” (Corazon et al., 2012, p.341). Clients described this

process as “feeling held by being among life, where death happens and

life goes on. It feels spiritual; it feels connected.” (Tarrant, 2019, p.21).

The use of live nature metaphors was another more active approach

to incorporating nature. Nature-based metaphor was ﬁrstly used to

foster acceptance by relating human diﬃculties to “the uncontrolled

dynamics of nature” (Berger, 2009, p.47), such as “leaves falling in the

autumn, uncontrollable weather, [and] planting seeds but [being un-

able] to control the outcome” (Corazon et al., 2012, p.341). Nature

metaphors were also used to support clients in ﬁnding new meaning

and becoming more self-aware. For example, one client identiﬁed with

their internal emotion when looking out at rough sea and reﬂecting

“that's how I feel - just churned and churned and churned, and I'm just

constantly going around in circles” (Revell & McLeod, 2017, p.279).

Lastly, metaphor was used to internalise the power of nature, building

strength and value-driven behaviour (e.g., “Julia brought seeds of

yellow-weed and said, ‘I want to free myself; to ﬂy and go where the

wind takes me, just like these seeds.” Berger, 2010, p.69).

At the more active end of the continuum was the analysis of nature

interactions. In this approach, the practitioner would observe the client's

behaviour, such as when selecting a place to sit, building a shelter, or

engaging in an outdoor pursuit activity. The practitioner and client

drew meaning from how the client thinks, feels, and behaves in re-

sponse to these interactions. This form of psychoanalysis beneﬁtted

from seeing clients in real life situations (e.g., “there is so much I can

read from a client because of their pace. Are they walking fast, plodding

along, or is there heaviness to their walk?” McKinney, 2011, p.103).

Practitioners felt nature therefore provided a valuable window into the

conscious and subconscious internal world of the participant:

… as [the client] spent time in the outdoors and had opportunities to

contrast his old familiar environment with his new unfamiliar en-

vironment, he began to identify aspects of his life that he did not

want to maintain going forward.

(DeMille & Montgomery, 2016, p.8)

Nature was also used to build relationships, social support and social

competencies, between clients, families, and practitioners. This oc-

curred through ‘being’ with one another in nature, sharing vulner-

abilities, learning from each other, and systemic observations of “per-

sonalities, structure of discipline, family values, and relationships”

(Portrie-Bethke et al., 2009, p.329). One article described the practi-

tioner's role as “both a guide and also just to be with them and moving

them along, someone who could point things out along the way or

deepen the experience that they're on, like a co-journeyer, co-ad-

venturer” (King & McIntyre, 2018, p.122). Relationships were also

developed between the client and nature, in such a way that nature

became a secure and familiar base, such as in clients who reported

feeling “reassured when they return to base camp after some days

away…” (Bettmann & Jasperson, 2008, p.55).

Other approaches for actively incorporating nature included ex-

periential learning through role play activities (e.g., ﬁctional adventures

or building homes/therapeutic spaces in nature), which used concepts

from drama therapy and distancing “to allow participants to experience

roles and situations which might be diﬃcult for them to cope with in

their everyday life” (Berger & McLeod, 2006, p.83). Clients were also

S.J. Cooley, et al. Clinical Psychology Review 77 (2020) 101841

able to learn from others who were modelling eﬀective and appropriate

behaviour whilst negotiating nature's challenges. For example, “men

being non-judgmental and vulnerable with other men increased parti-

cipants' ability to share and be vulnerable.” (Scheinfeld et al., 2011,

p.190), as well as the re-modelling of certain prejudices in those

growing up in diﬃcult social systems:

Central to our work is a mixed-gender therapy team. We believe it is

important for the adolescents to see women in leadership roles, men

and women cooperating and taking care of each other, men listening

and validating women's opinions and men behaving in non-abusive

ways and respecting others …

(Lambie et al., 2000, p.103).

Finally, through actively incorporating nature into therapy, clients

were able to build new narratives for their life experiences, for example:

It is common for abused women to focus on their failings. By tapping

into the courage needed to tackle perceived diﬃcult challenges such

as hiking up a mountain, a powerful opportunity to question nega-

tive self-deﬁnitions opens up.

(McBride & Korell, 2005, pp.4–5)

Sometimes activities were used to encourage and embed these new

narratives, such as throwing old narratives into an open ﬁre or river:

On arriving at a narrow bridge crossing the river, participants were

asked to ﬁnd a physical element from the surroundings that sym-

bolized a sensation, feeling, or thought from which they would like

to depart, say something about it, and throw it into the river.

(Berger & McLeod, 2006, p.90)

7.8. Potential issues

Practitioners needed to be acutely aware of potential practical,

therapeutic, and organisational issues. Practical issues included the

weather and terrain and the potential risk to physical safety. On occa-

sion, some clients “… did not come prepared with adequate or appro-

priate footwear/clothing…” (Revell & McLeod, 2016, p.40). Other

times, the chosen activity was found to be “too physically demanding”

(Jordan & Marshall, 2010, p.350) or the “rain, cold and windy condi-

tions – all aﬀect[ed] the session in some way.” (Revell & McLeod, 2016,

p.40). Another practical issue was access; diﬃculty accessing natural

spaces from the therapy room (e.g., “the placement of our oﬃce by a

busy highway with very little grassy area” Wolsko & Hoyt, 2012, p.19),

or when practitioners were outdoors, they were unable to access useful

resources and computers back in the therapy room (e.g., Revell &

McLeod, 2016).

The main therapeutic issue was the unpredictability of the natural

space “that does not necessarily have human-made boundaries [and] is

open to the world's inﬂuences” (Berger, 2010, p.71), which made it

more diﬃcult for practitioners to maintain structured boundaries or

frames. For example, keeping to time was more challenging than in-

doors, as was negotiating “back to back appointments, needing to

change clothes to accommodate outside sessions.” (Wolsko & Hoyt,

2012, p.19). Relational boundaries were also found to take on diﬀerent

forms, as described by Jordan and Marshall (2010):

This had given her a strong sense of mutuality as described above,

but also wanting to lose the asymmetrical part of our relationship. I,

in turn, found myself struggling with this challenge in the sense that

I began to wonder if indeed a friendship would be OK, but felt that I

‘ought’ to hold the boundary. Working in the outdoors had increased

my sense of involvement with the client, and the increased sense of

mutuality began to seem to lead naturally to friendship. (p.355)

Occasionally, it was also diﬃcult to predict “the client's psycholo-

gical condition and/or the diﬀerent ways in which the environment can

inﬂuence it” (Berger, 2010, p.72). At times, exposure to nature

prompted “feelings of insecurity and disempowerment.” (McBride &

Korell, 2005, p.11) and at worst was found to have “reactivated a

posttraumatic experience, which completely overwhelmed her”

(Berger, 2010, p.73). There were also reports of clients and practi-

tioners being distracted from therapy due to the dynamic scenery,

physical exertion, or because non-verbal cues were diﬃcult to detect

when positioned side-by-side:

… the physicality of walking side by side, sometimes resulted in not

hearing clients clearly, therefore had the potential to interrupt the

therapeutic process … Both clients' and therapists' attention could

[also] be aﬀected by the view, and this was seen to raise the po-

tential for the therapeutic process to be interrupted.

(Revell & McLeod, 2016, p.40)

A ﬁnal therapeutic issue related to unpredictability was a diﬃculty

controlling ethical practice guidelines, in terms of beneﬁcence (do

good) and non-maleﬁcence (do no harm) (e.g., “When therapy occurs

within an indoor space, variables that aﬀect the safety and comfort of

the client can be controlled for with relative ease” Hooley, 2016, p.

216). This issue centred predominantly around maintaining con-

ﬁdentiality, whereby therapy in public outdoor spaces would at times

be exposed to passers-by (e.g., “there are moments where I want to go

deeper with the client and we may be in too much of a public situation

to delve into it.” McKinney, 2011, p.101). This included an increased

risk of clients being seen by someone they knew, and/or revealing a

therapy encounter the client wished to remain conﬁdential.

The organisational issues ﬁrstly comprised a perceived dominance of

the biomedical model, described as the viewing of presentations as

diagnostic symptoms that need to be “conquered or eliminated”, rather

than “as feedback within a larger system which includes the more-than-

human world” (Conn, 1998, p.182). Jordan (2014) spoke of how the

current system is “convincing the public its suﬀerings are internal and

therefore treatable by the status quo that exists within traditional

therapeutic models” rather than “positing problems within the in-

dustrial growth of society and the ills this brings to bear upon both the

planet and the species who inhabit it” (p.369). A biomedical standpoint

was felt to be more suited to clinical therapy room settings and con-

trollable, repeatable therapy models, rather than more unstructured

and holistic therapy in natural spaces:

Counseling psychology is currently struggling to uphold the value of

diﬀerent ways of working in health providing services that are

dominated by an ideology that extols the provision of one, easily

manualised, short term therapy which can be oﬀered by large

numbers of people with relatively little training on the grounds that

it is ‘evidence based’ (Goldstein, 2007). The drive to eﬃciency,

calculability, predictability, the control and use of non-human

technologies, and the irrationality of rationality – or ‘McDonaldi-

sation’ (Strawbridge, 2002) is hard for counseling psychologists to

avoid, particularly if they are employed with the label of Scientist-

Practitioners in industry and education as well as the NHS. While it

is important that we oﬀer the best service to our clients, it is ques-

tionable that such a ‘one-size-ﬁts-all’ approach will in the longer

term, be as eﬀective and eﬃcient as fundholders hope.

(Shillito-Clarke, 2008, p.87)

Another, related organisational issue was a perceived lack of gui-

dance and support from the wider profession, which comprised a lack of

policy guidelines, theoretical frameworks, likeminded supervisors,

funding, and specialist training:

I don't have anyone for supervision who does walk and talk therapy,

so a lot of things, I just make up as we go. It requires a lot of ﬁguring

out on my own. There are no leaders.

(McKinney, 2011, p.98)

It was suggested that “educators could lead the training eﬀort by

developing ethical guidelines and best practices for ecotherapy and by

S.J. Cooley, et al. Clinical Psychology Review 77 (2020) 101841

teaching core beliefs of ecotherapists in the core coursework of mental

health counseling and psychology programs” (King & McIntyre, 2018,

p.123).

7.9. Possible solutions

The possible solutions for mitigating issues began with a thorough

assessment and formulation of clients' physical and psychological suit-

ability and potential beneﬁts of outdoor therapy. Health screening

questionnaires “were utilised as a means of assessing physical suit-

ability” (Kyriakopoulos, 2010, p.314) and clients were asked to check

with their GP if there were any physical concerns. Clinical judgement

was used to establish the suitability of mental health presentations and

appropriateness at particular stages of therapy (e.g., stabilisation vs.

trauma processing); for example, “I [the practitioner] wouldn't want to

process traumas on the trails, I think sitting in an oﬃce in a contained

space is more ethical” (McKinney, 2011, p.98). Practitioners also in-

corporated the relationship with nature into their assessment and for-

mulation:

For those of us who primarily draw on Western models of therapy

and of formulation, it would be useful to consider what a formula-

tion would look like that brought ecological or evolutionary factors

into account alongside the cognitive and psychodynamic …

Alongside traditional questions such as ‘Tell me about your Mom

and Dad,’ or ‘Describe your relationship with your partner,’ I ﬁnd

that clients often respond well to an invitation to ‘Tell me about

your relationship to the natural world’.

(Milton, 2009, p.11)

Potential adaptations to the natural space were also considered

during this time, such as movement up or down the aforementioned

continua of intensity of the interaction with nature and the active or

passive way it is incorporated into the talking therapy (Fig. 3; e.g.,

“Working in a natural environment, near the hospital, within a limited

time frame, minimized the workshop's risks and reduced anxieties, al-

lowing this population to beneﬁt from a creative encounter with

nature.” (Berger, 2010, pp.69–70). Assessment and formulation led to

clear functions and individualised treatment plans for taking therapy

outdoors, as well as careful considerations of how a client might re-

spond to diﬀerent settings:

Working with diﬀerent clients in varied environments, at diﬀerent

times of the year and diﬀerent times of the day, it became clear to

me that this factor inﬂuences the entire therapeutic encounter, as it

shapes the emotional, physical, and imaginary spaces. As such,

working in a shaded forest will create a diﬀerent atmosphere than

working in a hot desert, and working on a windy morning on the

beach will foster diﬀerent progress than working on the same beach

under the moonlight. Exploring and articulating nature therapy, it

became clear that people are inﬂuenced by diﬀerent characteristics,

including not only their feelings and sensations but also the mem-

ories they evoke, their way of thinking, and the metaphors they

encounter.

(Berger, 2007, p.42)

Formulation was also used to ensure that the decision to work

outdoors was not driven solely by the practitioners' biases and personal

aﬃliation with nature:

I wrestled with the sense that moving outside could be seen as an

enactment on my part, a physically embodied way of wanting to

move away from being stuck with this particular client.

(Jordan & Marshall, 2010, p.356)

Informed consent was the next solution, whereby the practitioners

ﬁrstly provided “a presentation of particular experiences and risks the

client may encounter, especially related to experiences and risks that

may diﬀer from traditional psychotherapy taking place within indoor,

bounded spaces.” (Hooley, 2016, p.219). The practitioner and client

could then work together in contracting these potential barriers and the

steps they would take to mitigate them. These discussions ensured the

client was fully informed of what could and could not be controlled in

the outdoors, as well as alternative indoor treatment options, before

giving their informed consent. For example:

How might they respond if they meet another person? What will be

important for the client and therapist to do in that moment? In this

way, the client and therapist can negotiate a strategic response be-

fore an event occurs, allowing the client to collaborate in the process

of protecting his privacy and conﬁdentiality … Therapists who

communicate clearly to the client the ways in which his or her

privacy will be respected and the particular limits of conﬁdentiality

lay the groundwork for a productive therapeutic alliance with the

client.

(Hooley, 2016, p.219)

Once this initial contract was agreed, process contracting became

imperative, which involved regularly referring back to and adapting the

agreed contract as the relationship progressed and as new issues arose

within the dynamic outdoor environment (e.g., “I do a mini assessment

in the beginning of the session to see if sitting or walking is best for

them that day.” McKinney, 2011, p.92). Process contracting was de-

scribed as “a reiterative, collaborative and co-constructed contracting

process” (Revell & McLeod, 2017, p.281). Sometimes this involved

holding “the client at the edge of their experience in a way that maybe

uncomfortable but will not become overwhelming.” (Jordan &

Marshall, 2010, p.352) and other times the therapy work was con-

sidered more suitable indoors (e.g., “there may be instances when

meeting in an oﬃce may be more appropriate for certain issues.”

McKinney, 2011, p.92).

Although there were aspects of outdoor therapy that could not be

controlled, containment was still achieved by introducing predictability

in other aspects of the therapeutic frame, including pre-planned time

frames (e.g., “The total walk and talk time allotted was 45 minutes but

because of time needed to dress appropriately, actual walk and talk

time was about 30 minutes.” Doucette, 2004, p.379), maintaining

agendas, using private outdoor spaces, and combining indoor and

outdoor therapy (e.g., “I always hold initial sessions indoors, in a safe

and controlled setting, before suggesting we try outdoor work.”

Tarrant, 2019, p.22). Jordan and Marshall (2010) describe how the

outdoor environment is not entirely uncontrollable:

It is still possible and maybe at times desirable, for the therapist to

assert some sense of control of the outdoor space rather as they

might indoors, introducing more elements of predictability into the

mix. This might involve providing a specially created outdoor space

(Santostefano, 2004), or sticking to a prescribed route or place to sit.

One of the authors has found it easier to conduct one to one therapy

outdoors in a space that mimics the indoors in the form of a willow

dome.

(Jordan & Marshall, 2010, p.355)

The ﬁnal solution for safeguarding practice was through risk as-

sessment and being aware of professional limits of competence, such as

knowing when and how to seek external guidance. For example, some

practitioners worked alongside outdoor pursuit instructors when in-

corporating more adventurous activities (e.g., “…professional guides

are used on activities where there is a high risk of injury; for example,

caving, white water rafting and abseiling.” Lambie et al., 2000, p.103).

Hooley (2016) discovered a need for seeking more creative supervisory

collaborations:

an occupational therapist might oﬀer perspective in understanding

the ways a client might respond to the physical demands of a nature-

based therapy. A horticulturist might assist in identifying safe and

appropriate plants for use in therapy. A seasoned river guide might

S.J. Cooley, et al. Clinical Psychology Review 77 (2020) 101841

help identify potential hazards in an adventure therapy excursion. In

the absence of supervision by a qualiﬁed psychologist, such creative

collaboration and oversight can contribute to a deeper under-

standing and implementation of both theory and practice.

(Hooley, 2016, p.218)

This collaboration also included checking “with my indemnity in-

surer as to any safeguards I need to make” (Tarrant, 2019, p.21). In

addition, practitioners were required to be proactive in seeking out

additional training opportunities not routinely provided in their stan-

dard professional training, such as “knowledge of the chosen wilderness

context” and “ﬁrst aid” (Hooley, 2016, p.218). Hooley (2016) warned

that the current lack of professional guidance “does not represent an

excuse to proceed with a novel intervention without ﬁrst developing

professional competency” (p.217).

7.10. Enrichment

Whilst the practitioner-client dyad inevitably retained some degree

of asymmetry (i.e., the client remained a client and practitioner re-

mained their practitioner), clients felt like their encounter in a natural

space provided a greater sense of mutuality compared to that of a con-

sultation room. This included greater mutuality of space:

the client is free to choose the setting that feels right for them.

Sometimes this is a conscious decision; sometimes they let their

‘body do the walking’, often surprising themselves when they ﬁnd

their ‘right spot’. They choose their seat; I check out where they

would like me to be before sitting where they want me to sit or

where feels appropriate….

(Tarrant, 2019, p.21)

And mutuality of relationship:

a key intervention for inviting the therapist to ﬂatten hierarchies, to

encourage the client to take ownership of their process, and to fa-

cilitate the therapeutic alliance … She reported experiencing a

stronger sense of me, her therapist, as a ‘real’ person in the ‘real

world’ experience of her therapy, rather than as a more separate

professional closeted in the therapy room.

(Jordan & Marshall, 2010, p.349–355)

This dynamic was particularly beneﬁcial in “theoretical approaches

that focus on mitigating the power diﬀerential such as feminist, social

constructivist, narrative, and many multicultural approaches to psy-

chotherapy” (King & McIntyre, 2018, p.123).

Clients also reported feeling removed from day-to-day norms and

from their mental health diagnoses and ‘symptoms’, providing greater

freedom for emotional expression, which helped some to detach and

“open up in a way they did not experience in a counseling oﬃce”

(Wiggins, 2018, p.114). Some felt this was because the outdoors pro-

vided a less pressurised environment:

To date, my clients primarily come with issues around relationships:

most notably, controlling and abusive relationships. They feel huge

pressure at work and at home. They report that the indoor therapies

they've experienced so far have also felt pressured. Outdoors, they

feel and relish the freedom.

(Tarrant, 2019, p.22)

One client noted, “if you sit around in a hospital, it just reminds you

that you are ill” (Fernee et al., 2019, p.1372), and another client said,

I have often felt very constrained in consultation rooms, particularly

when I am in a strong emotional state. I have on occasion felt limited

by the typically neat and - importantly – small space and often to

really explore emotional states I want to move.

(Jordan & Marshall, 2010, p.353)

Therapy was also enriched by combining mental processes with

bodily interactions with nature, resulting in a powerful and holistic in-

tegration of mind, body, spirit, and place. Clients became more physi-

cally active, in tune with their bodies, emotions and behaviours, and

also more connected with the practitioner at a deeper holistic level. For

example,

They have got stuﬀ going on in their head, stuﬀ going on in their

body and they don't integrate the two. When we are doing the

walking and talking, their mind and body are integrating… If they

are stuck in something I just ﬁnd that walking forwards and being in

motion helps.

(Revell & McLeod, 2017, p.278)

Physical movement also helped practitioners to connect with clients

psychologically (e.g., “tuning in to the rhythm of their movements– so

it's a physical sort of empathy …” Revell & McLeod, 2017, p.278). Other

practitioners spoke of the bilateral movement providing neurological

beneﬁts similar that that of Eye Movement Desensitization and Re-

processing therapy (e.g., “it gets you out of the left brain such as

EMDR.” McKinney, 2011, p.93).

Clients also experienced greater interconnectivity with nature, often

described as feeling a part of something larger and more meaningful.

This interconnectivity was also referred to as providing an opportunity

for an “other than Human experience” (Tarrant, 2019, p.21) and a

“technological disconnection” (Fernee et al., 2019, p.1363). For ex-

ample, one client developed “a sense of peace and connection to the

natural rhythms of the world that was more meaningful than his high-

pressured business world and lifted his depression more eﬀectively than

any amount of talking” (Shillito-Clarke, 2008, p.86). This inter-

connection at times resulted in improved community and environ-

mental behaviours (e.g., “she became transformed from a girl who

threw rocks at birds to one who tried gently to approach them and

stroke them.” Doucette, 2004, p.384), and clients felt like their re-

lationship with the outdoors provided a ‘therapy room’ they could re-

turn to by themselves to self-sooth or “empty out the self” (Revell et al.,

2014, p.285).

The ﬁnal area of enrichment to therapy regarded the practitioners'

well-being. Firstly, outdoor therapy increased their habitual physical

activity, which served to mitigate negative impacts of more sedentary

therapy approaches (e.g., “physical improvements such as better sleep,

decreased body fat, decreased cholesterol, and reduced risk of heart

attack.” McKinney, 2011, p.104). Secondly, practitioners reported a

reduction in stress and emotional fatigue. For example, one practitioner

described how the physical movement left them feeling “lighter … like

it hasn't left me with their feelings that sometimes I feel like I get left

with in a therapy room” (Revell & McLeod, 2017, p.280). Other prac-

titioners described how nature as a third person in the therapy shoul-

dered some of the therapeutic work, leaving them feeling “less weighed

down by the responsibility for being helpful” (Revell & McLeod, 2017,

p.280). Outdoor therapy was therefore considered both a “stress re-

liever and self-care for the therapist” (McKinney, 2011, p.105). Lastly,

therapy outdoors was found to bolster therapeutic skills in practi-

tioners, such as trust, conﬁdence, and creativity:

My own self-conﬁdence as outdoor therapist is also growing, as my

clients and I explore how outdoor therapy can help them. And with

this growing conﬁdence comes a growing trust in my client and how

to be with my client. Outside, I generally feel more spontaneous,

more creative, more in touch with us, both in relationship to each

other and within the wider world. I take my experience, learning

and ethics from inside to the outside. I hope that the reverse can also

be true: that I can bring back indoors my increasing spontaneity,

creativity and wider perspective for the beneﬁt of both the client

and me.

(Tarrant, 2019, p.22)

Some practitioners described feeling empowered by a new sense of

versatility:

S.J. Cooley, et al. Clinical Psychology Review 77 (2020) 101841

I think it has given me faith in my ability; faith in the fact that

therapy as a whole can happen literally anywhere … it's given me a

lot of conﬁdence just in the fact that I can oﬀer this ….

(Revell & McLeod, 2017, p.281)

8. Discussion

The aim of the present review was to explore the experiences of

practitioners (n= 322) and clients (n = 163) who have practiced

talking therapy in natural, outdoor spaces. The resulting themes were

organised into a framework (Fig. 3) to support future practice and re-

search in this area. This framework started with considerations sur-

rounding the suitability of the client and practitioner dyad to working

outdoors. Decisions are then made regarding the appropriate type of

outdoor environment and activity, such as walking in a local park (low

intensity) or a weekend wilderness retreat (high intensity). The natural

environment could either provide a passive backdrop to conventional

talking therapy, or be an active mechanism in the therapy.

There was a wide variety of approaches to therapy outdoors, which

were eﬀective in heterogeneous contexts, client groups, and presenting

problems. Therapy outdoors was also integrated with a range of therapy

modalities (e.g., CBT, third wave, psychoanalytical, relational, psy-

chodynamic, and systemic). This heterogeneity is reﬂected in the fact

that many articles provided a general commentary on therapy outdoors

without specifying a particular client group or presenting problem (see

Fig. 2). Thus deciding ‘when to use outdoor therapy?’ is not a question

that can be answered within absolute parameters. Rather, practitioners

are required to use their skills in individualised assessment and for-

mulation, considering such questions as, ‘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 out-

doors provide?’, ‘how does the outdoors ﬁt with the client's recovery

goals?’, ‘is the outdoors appropriate for what we have planned today?’.

For example, these formulations could be as simple as a client in need of

coping skills for anxiety, who reported feeling disconnected from a

previously positive relationship with nature, which led to the use of

outdoor mindfulness exercises (Corazon et al., 2012). In this way, the

process of deciding on the suitability of therapy outdoors is little dif-

ferent to how an integrative indoor practitioner would set about de-

termining what type of therapy model to use with a particular client.

The resulting framework (Fig. 3) is therefore recommended as a source

of reﬂexivity for those formulating whether and how best to combine

nature and therapy, rather than to oﬀer causally related mechanisms.

The typical issues encountered when working in nature included the

physicality of the outdoors, the unpredictability and distraction that

could aﬀect therapy work, and diﬃculty guaranteeing ethical processes

such as conﬁdentiality. These issues were supported by informed con-

sent, process contracting, instilling predictability in elements of the

therapeutic frame that could be controlled (e.g., timings, locations,

agendas), and being aware of professional competency. Fundamental to

ethical practice was ensuring that if at any point outdoor therapy was

deemed unsuitable, the work was taken indoors. In adhering to these

approaches, a beneﬁcial partnership between therapy and nature was

demonstrated across all articles.

Opinions varied when comparing the eﬀectiveness of therapy out-

doors to conventional indoor therapy. Some practitioners and clients

felt engagement with nature enhanced the speed of recovery (e.g.,

McKinney, 2011;Shillito-Clarke, 2008;Wiggins, 2018), whilst others

suggested that eﬀectiveness appeared no diﬀerent to indoor therapy

with both settings oﬀering equally valid alternatives (e.g., Jordan &

Marshall, 2010;Revell & McLeod, 2016). Either way, there was

agreement that natural spaces can oﬀer a unique contribution in terms

of freedom for expression, mind-body holism, interconnectivity, and

practitioner wellbeing. Therapy outdoors was also found to enhance the

therapeutic relationship through a greater shared ownership of space

and a more balanced power dynamic within the therapeutic relation-

ship (i.e., mutuality); an important ﬁnding given that the therapeutic

relationship is known to account for as much variance in therapy out-

comes as the treatment modality itself (Norcross & Lambert, 2011).

In line with the aforementioned theories of biophilia (Wilson, 1984)

and ecological systems (Bronfenbrenner, 1979), the therapy outcomes

and their maintenance were often associated with the connectivity to

nature that had deepened over the course of therapy (e.g., Berger &

McLeod, 2006;McBride & Korell, 2005;Revell et al., 2014). For these

reasons, and given the prior evidence for the restorative capacity of

nature (e.g., Bratman et al., 2012), many practitioners in the present

review not only explored a client's state of connectivity with nature as

part of their initial assessment, but also integrated it within their for-

mulation (e.g., Milton, 2009;Wolsko & Hoyt, 2012).

Incorporating nature connectivity and nature restoration into for-

mulations is not a new consideration. If we return to the original pro-

positions of the bio-psycho-social formulation model, the ‘biosphere’ is

positioned as the broadest system of inﬂuence in which our biological,

psychological, and other social systems reside (Engel, 1980). Engel

explained that “neither the cell nor the person can be fully character-

ized as a dynamic system without characterizing the larger system(s)

(environment) of which it is a part.” (p. 537). Despite these prior the-

ories and the wealth of empirical evidence for nature restoration

mentioned earlier, conventional formulation rarely considers systems of

inﬂuence beyond that of the immediate human systems surrounding a

client (Johnstone et al., 2018). In the words of the founder of ecopsy-

chology (i.e., the study of humans' relationship with earth), conven-

tional therapies “seek to heal the alienation between person and person,

person and family, person and society”, whereas therapy outdoors has

the additional objective of healing “the more fundamental alienation

between the person and the natural environment” (Roszak, 1992,

p.320). Given the ﬁndings of the present review, it is perhaps timely to

update traditional Western models of talking therapy, which were de-

vised nearly 150 years ago, and in an age of rapid increases in urba-

nisation and post-industrial revolution (Jordan, 2015;Roszak, 1992).

Incorporating therapy outdoors would also be in line with more

recent calls for practitioners to take greater responsibility for environ-

mental behaviours and climate change (e.g., The American Psychology

Association Task Force on the Interface Between Psychology and Global

Climate Change, 2010). The present review included evidence to sug-

gest that greater connectivity with nature, resulting from therapy out-

doors, led to improved community and environmental behaviour (e.g.,

Doucette, 2004). This relationship has been conﬁrmed by a number of

studies showing nature connectivity to have a positive relationship with

an individual's environmental concerns and positive environmental

behaviours such as recycling and consumerism (e.g., Gkargkavouzi,

Halkos, & Matsiori, 2019;Nisbet & Zelenski, 2013).

However, rather than embracing this more holistic approach to

psychological intervention, health services in the present review largely

favoured traditional Cartesian clinical approaches, more aligned to a

reductionist, biomedical model of treatment (Conn, 1998;Jordan,

2014). This is perhaps why the majority of practitioners were working

in private practice or academic institutions, oﬀering them more

freedom and ﬂexibility to break away from convention and work out-

doors (Shillito-Clarke, 2008). Perhaps due to these issues surrounding

organisational culture, this review identiﬁed a disparity in the dis-

tribution of professionals, in which counsellors and psychotherapists

featured more prominently, with clinical psychologists markedly less

so. On one hand, this ﬁnding may be surprising, given that psychody-

namic psychotherapy and psychoanalysis is typically associated with

greater rigidity in the boundaries of the therapeutic frame, and with

clinical psychology typically operating more ﬂexibly across models

(Lemma, 2015). However, it is also possible that the high client volume,

biomedically-informed, and protocolised services that clinical psy-

chologists often ﬁnd themselves operating within make taking their

work outside of the clinical setting more challenging (Johnstone et al.,

S.J. Cooley, et al. Clinical Psychology Review 77 (2020) 101841

2018;Mind, 2013).

If outdoor therapy was more recognised and supported by profes-

sions and public health services, it would also have the potential for

important service-level impact. Notably, it could provide clients with

greater ﬂexibility in treatment options and therefore increase equity of

access for those averse to indoor therapy. As an adjunct, therapy out-

doors could also mitigate demand for clinic rooms; all of which are

common limitations of mental health services (Mind, 2013). From a

ﬁnancial standpoint, articles in the review tended not to discuss the

costs associated with therapy outdoors, but one did report passing on

their savings to private clients, “in moving outside we contracted for

her to pay less as we didn't have to cover the costs of the room, she

agreed to this arrangement as she was struggling with the costs of the

therapy” (Jordan & Marshall, 2010, p.356).

An additional service-level implication is the engagement of both

mind and body within the one treatment. A more holistic approach to

therapy may beneﬁt the challenge of multi-morbidity currently faced by

health services, with mental health diﬃculties presenting alongside

physical health problems associated with sedentary lifestyles (Bramley

& Moody, 2016;NICE, 2016). The present review also revealed beneﬁts

to practitioner well-being as a result of working more holistically. It is

often said that ‘one cannot serve from an empty vessel’ (Brown, 2014),

and yet, mental health services often report high rates of staﬀ burnout

and absenteeism (Rupert, Miller, & Dorociak, 2015). A treatment ap-

proach that is found to beneﬁt both the client and practitioner should

therefore be considered a signiﬁcant asset.

Given that therapy outdoors is increasing in popularity, calls were

made in the present review for this to be reﬂected in practitioner

training curricula (e.g., King & McIntyre, 2018). Ethically, this may be

an important and necessary addition given that some practitioners

drawn to this way of working ﬁnd themselves having to ‘make it up as

they go’ without any formal training or guidance from their core

training (e.g., Hoover & Slagle, 2015;McKinney, 2011). Findings from

this review suggests training could include raising awareness of the

potential beneﬁts of nature connection and therapy outdoors, assess-

ment and formulation techniques to determine suitability, how to in-

tegrate existing therapy models, and the safe facilitation of outdoor

therapy. In collating the body of literature in the ﬁeld thus far, the

present review may help to instigate and guide such training provision.

9. Limitations and future research

Future research is now needed to further explore and develop the

framework for outdoor therapy presented herein. Consonant with the

majority of articles included within it, the review sought to provide a

general overview of therapy outdoors. This overview included a range

of complex topic areas, many with their own literature-base in con-

ventional indoor therapy (e.g., informed consent, conﬁdentiality,

therapeutic and relational boundaries, formulation, risk etc.). It is for

this reason that readers are directed to the table of themes in the online

supplementary material for a more extensive presentation of the data

surrounding each aspect of the framework. Future research may be

required to expand upon speciﬁc areas of this framework. In addition,

given that the ﬁndings of the present review were limited to articles

written in English, the ﬁeld may also beneﬁt from greater exploration of

other countries where outdoor therapy practice is well established.

Organisational constraints noted in this review, suggesting practi-

tioners wishing to practice outdoors may be enabled better in private

rather than public health services, risks constraining the growth of

outdoor therapies if rigidly adherent to medicalised treatment models.

Such constraints may force practitioners from mainstream services,

reducing access to ethical and eﬀective approaches to therapy outdoors,

which become the preserve of clients who can aﬀord to access them

privately. Research approaches, such as those guided by implementa-

tion science (see Nilsen, 2015), could explore how therapy outdoors

could be better incorporated into mainstream services. For example,

case studies could be carried out in services where therapy outdoors is

introduced to explore the barriers, enablers, and resulting impact on

clients, practitioners, and service outcomes.

A further limitation of the present review is that the included re-

search is almost exclusively conducted by pioneer practitioners and

researchers who are homogenous in their personal and professional

aﬃliation with nature. Limited in number relative to the wider prac-

titioner population, their views are invaluable in ascertaining what

therapy outdoors can look like as a treatment model. However, further

research is now required with practitioners, service users, policy ma-

kers, educational leaders, and service leads, who may view this practice

with less enthusiasm. Such perspectives may help to guide and imple-

ment future outdoor practice.

10. Conclusions

In summary, this review is the ﬁrst to provide an extensive review of

client and practitioner experiences of combining talking therapy with

the outdoors. A systematic search of the literature revealed a wealth of

articles dating back 25 years. Following meta-synthesis, a framework is

provided outlining key considerations for the planning and facilitation

of this novel and enriching practice. Therapy outdoors was eﬀective not

only in connecting clients with the natural world, but also through

enriching the therapeutic encounter; providing novel ways of in-

corporating conventional therapy approaches, with added mutuality,

holism, freedom of expression, and enhanced practitioner wellbeing.

Beneﬁts of therapy outdoors were not exclusive to particular client

groups, and its use is therefore recommended using a person-centred

approach based on individualised formulation. Future research is now

needed to shape the implementation of therapy outdoors in practitioner

training programmes and mainstream services.

Role of funding sources

No ﬁnancial support was received towards the conduct of this re-

search and manuscript preparation.

Contributors

Authors SC and NR designed the study. Author SC conducted the

literature review and wrote the ﬁrst draft of the manuscript. All authors

contributed towards the analysis. All authors contributed to and have

approved the ﬁnal manuscript.

Declaration of competing interest

All authors declare that they hold no conﬂicts of interest.

Acknowledgement

The authors wish to thank Research Consultant Selina T. Lock for

her support in literature searching.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://

doi.org/10.1016/j.cpr.2020.101841.

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‘Into the Wild’: A meta-synthesis of talking therapy in natural outdoor spaces

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