The use of talking therapy outdoors

Abstract

Outdoor talking therapy is an evidence-based approach. It is typically used to combine the conventional outcomes of indoor therapy with the known benefits of connecting with the natural world. Meeting with clients in open, outdoor spaces can permit an authentic, human-to-human encounter, whilst at the same time allowing for physical distancing in line with current Covid-19 government recommendations. Therapy outdoors is supported across diverse client groups and therapy modalities. However, therapy outdoors will not suit all clients, practitioners and services. This guidance document is intended to support individualised assessment and formulation when considering therapy outdoors (e.g. suitability of approach based on client and presenting problem, choice of outdoor activity, practicalities and issues concerning safety, consent and confidentiality). This document is not intended to supersede local guidance. It is recommended that the practitioner consults relevant policy documents and guidance in their service or professional body. This document should be used in conjunction with appropriate critical thinking and clinical reasoning.

Full text

GUIDANCE
The use of talking therapy outdoors
Guiding principles:
Outdoor talking therapy is an evidence-based approach. It is typically used to
combine the conventional outcomes of indoor therapy with the known benefits of
connecting with the natural world.
Meeting with clients in open, outdoor spaces can permit an authentic, human-to-
human encounter, whilst at the same time allowing for physical distancing in line
with current Covid-19 government recommendations.
Therapy outdoors is supported across diverse client groups and therapy modalities.
However, therapy outdoors will not suit all clients, practitioners and services.
This guidance document is intended to support individualised assessment and
formulation when considering therapy outdoors (e.g. suitability of approach based
on client and presenting problem, choice of outdoor activity, practicalities and issues
concerning safety, consent and confidentiality).
This document is not intended to supersede local guidance. It is recommended that
the practitioner consults relevant policy documents and guidance in their service or
professional body. This document should be used in conjunction with appropriate
critical thinking and clinical reasoning.
Introduction
In response to the Covid-19 pandemic, practitioners and services have been required
to review their continuity plans. Alternatives to conventional face-to-face therapy have
largely centred around offering therapy remotely (e.g. telephone or video calling)1.
Although helpful, some practitioners and clients have expressed difficulties with these
approaches, such as access to equipment, digital literacy, and restricted non-verbal
communication2. This guidance document considers the outdoors as another context for
offering talking therapy, which may be of particular interest in situations where digital
approaches are unavailable or do not meet the needs of the client or practitioner.
Those who are familiar with working outdoors find that when outdoor spaces are used
appropriately, they provide a safe and effective space for therapy3. These practitioners
and their clients have reported a range of benefits unique to outdoor talking
therapy3, such as:
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• promoting access and equity of care for clients who find an indoor therapy room encounter
too uncomfortable (e.g. its perceived pressure and formality, feeling trapped
or pathologised, experiencing difficulties with cognitive and attentional capacity);
• enabling clients to experience greater shared ownership of the therapy space and
relationship;
• greater freedom of expression through a sense of escape from day-to-day routines and
environments that the client has associated with their difficulties;
• physical movement and/or dynamic surroundings supporting psychological flexibility in
those who feel psychologically ‘stuck’;
• restorative effects of time spent in natural settings (e.g. reduced blood pressure and
stress levels);
• interconnectedness with the natural world providing a sense of belonging and wellbeing;
• a deeper connection to the natural world supporting positive and reciprocal environmental
behaviours;
• nature’s consistent and indifferent stance towards a person’s perceived flaws and
vulnerabilities providing stability and different perspectives on problems; and
• holistic benefits to the clients’ and practitioners’ physical as well as psychological health.
In light of the Covid-19 pandemic, outdoor talking therapy may offer additional benefits to those
listed above. Current government guidance aims to reduce the spread of the virus through social
distancing, which includes reducing unnecessary footfall in contained public places, utilising
outdoor spaces and maintaining safer distancing when people do come into contact4. Meeting
a client in an open, outdoor space may offer an authentic, human-to-human encounter, whilst at
the same time allowing for the recommended physical distancing.
This guidance document outlines considerations for ensuring outdoor talking therapy remains
a safe, contained and ethical form of practice. The guidance is informed by an in-depth and
systematic review of the literature, which was published open-access in the journal Clinical
Psychology Review (Cooley et al., 2020). The review synthesised the experiences of 322
practitioners (clinical psychologists, counselling psychologists, counsellors, psychotherapists,
family therapists, clinical social workers and CBT therapists) and 163 service users, all of whom
had engaged in outdoor talking therapy*. Articles encompassed a range of client groups
(e.g. diverse presenting problems, age groups, ethnicities, health and physical abilities and
cognitive ranges), therapy types (e.g. individual, group, couple and family work), and therapy
models (e.g. CBT, third wave, psychodynamic, play therapy and systemic). Since this review
was published, the present guidance document has been co-produced with a further sample of
practitioners and service users, including those from service user reference groups, the ACP-UK
and the BPS DCP Faculty of Holistic Psychology.
*To explore the primary research findings in outdoor talking therapy, readers are directed to the review
by Cooley et al. (2020). A selection of primary research is also provided at the end of this document.

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Considerations for outdoor talking therapy
If therapy outdoors is unfamiliar to the client or practitioner, it may be useful to first reflect
on a more familiar context (e.g. indoor therapy) and identify aspects of therapy most valued or
considered essential. These aspects may include not wanting to be seen or overheard by others,
having therapy in the same space each time, having clearly defined roles between the client and
practitioner and the client being free to leave or end a session before the allotted time. It is then
important to consider which, if any, of these elements are possible to maintain in the available
outdoor setting(s). The following sections are designed to support this decision making process.
OUTDOOR LOCATION AND ACTIVITY
During therapy, the outdoor encounter can vary from low to high intensity with regard to the physical
demand, duration of time spent outdoors and the degree of interaction between person and nature.
LOW INTENSITY
Low intensity encounters include sitting outdoors and light walking, of a duration similar to that of
indoor therapy. This may take place in areas of natural beauty such as rivers, lakes, mountains and
coastal locations. Where access to these areas is limited, such as in urban locations, other viable
options include sitting outside the back of a therapy room, local parks, gardens and footpaths.
MODERATE INTENSITY
During moderate intensity encounters, there is a more ‘hands-on’ interaction with the outdoors.
Examples include horticulture, fruit picking, problem-solving and outdoor play activities, outdoor
pursuits (e.g. hiking, climbing, paddle sports) and building shelters to sit and talk beneath.
HIGH INTENSITY
The high intensity end of the continuum is less commonly described within literature specific to
talking therapies. This approach typically comprises wilderness expeditions or ‘adventure therapy’,
where groups are led by an outdoor instructor and live outdoors for a number of days or weeks,
whilst engaging in various outdoor adventure activities (e.g. trekking, canoeing and building
shelters and open fires for cooking). In this context, the practitioner will accompany the group
either for the whole trip or elements of it and offer intermittent group and/or individual therapy.
ASSESSMENT AND FORMULATION
PRACTITIONER SUITABILITY
Practitioners who regularly engage in therapy outdoors typically report a natural affinity with
the outdoors, such as a feeling of security, connection and belief in its restorative potential.
They also report benefiting from flexibility in their chosen therapy modality, or an ability
to integrate multiple modalities, as they creatively adapt the approaches they use indoors.
At a minimum, a practitioner needs to be aware of changing relational dynamics, comfortable
enough in the chosen space so that it assists them in their delivery of therapy, and suitably trained
if using certain moderate or high intensity outdoor activities.
WORKPLACE SUITABILITY
The practitioner’s employing organisation or place of work may also need to be supportive of
therapy outdoors. The available evidence suggests that organisations that value a more holistic
rather than bio-medical approach to mental wellbeing are often more supportive of outdoor talking
therapy. Support from within the workplace may include managerial permission, having adequate
insurance, and supervisory support from colleagues and multidisciplinary teams.

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CLIENT SUITABILITY
Previous research has found outdoor therapy to be effective across a range of client groups
and presenting difficulties. This research has not attempted to provide absolute parameters or
categorisation of client suitability. Suitability should therefore be determined on an individual
basis using person centred considerations during assessment and formulation. Considerations
should include whether the presenting psychological difficulties (e.g. trust, shame, anxiety) could
be exacerbated by working outdoors.
Some clients may report an affinity with outdoor spaces through a sense of containment,
familiarity, excitement, connection, positive childhood memories, and/or previous therapeutic
experiences. Other clients may not share such an affinity or be fearful of certain outdoor
environments5. At a minimum the client needs to feel comfortable enough in the chosen space
so that the space does not impede their ability to engage with therapy over and above that of
alternative indoor spaces. At times, the client’s reaction to therapy outdoors may be difficult
to predict and assessment for suitability is therefore an on-going process, as described in the
‘informed consent’ section below.
RISKS IN THE OUTDOOR CONTEXT
Approaches to mitigating risk include selecting an outdoor space in close proximity to
communities, familiarity and assistance (e.g. utilising outdoor spaces within the grounds of the
therapy service); using lone working safety measures (e.g. informing colleagues of timings and
location and carrying a mobile phone and/or lone worker device); and having more than one
practitioner present (e.g. co-facilitating a group with a support worker). Outdoor talking therapy
that involves a lone practitioner in a remote location is typically only used with clients considered
of low risk to themselves and others.
If there are concerns regarding a client’s physical safety during physical activity and/or exposure
to inclement weather (e.g. pre-existing injuries and health conditions), physical health screening
tools or confirmation from the client’s GP may be necessary. It is also important to consider
whether the outdoor setting is accessible for those with mobility difficulties and whether toilet and
refreshment facilities are required.
Practitioners should use their clinical judgement as to whether the type or stage of therapy is
suitable for a particular outdoor context. For example, some outdoor environments may lend
themselves to stabilisation work and developing emotional regulation skills, yet be less appropriate
for processing a trauma that is less predictable and highly emotive.
It is also advisable to carry out a risk assessment of the outdoor environment. This risk assessment
should include the documentation of any hazards (i.e. anything that has the potential to cause
harm), their associated level of risk (i.e. the likelihood of the potential harm being realised) and
how the practitioner plans to remove or reduce these risks. Hazards may include challenging
terrain, changing weather, lighting conditions and emotional triggers. Whilst it is impossible for
an activity to be completely devoid of any risk, practitioners are expected to take reasonable steps
in minimising them. Some employers will have their own risk assessment form, or ‘positive risk
assessment form’ and a dedicated health and safety officer to support with this process (see the
useful resources section at the end of this document for examples of risk assessment).
THERAPY GOALS
Before embarking on outdoor talking therapy, it is useful to consider whether this is solely
a pragmatic choice arising from limited alternatives due to Covid-19 restrictions, or whether
the outdoor environment can support the client’s formulation and therapy goals. For example,
previous research and theories, such as the bio-psycho-social model6 and the biophilia
hypothesis7, formulate how a harmonious and reciprocal relationship with the natural world

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can be an important protective factor for psychological wellbeing, or if absent, a source of
psychological distress.
To explore whether the outdoors could play a more active role in the client’s recovery goals, the
practitioner’s routine assessment questions could be supplemented with questions such as,
‘How would you describe your current relationship with nature/the outdoors?’, ‘What has this
relationship been like at other times in your life (e.g. childhood)?’, ‘When and where do you
feel safest in nature?’, ‘When and where do you feel unsafe in nature?’, ‘How do you feel about
the idea of meeting outdoors for some of our therapy?’ (see the useful resources section for a
‘connection to nature’ assessment protocol published by the Royal College of Psychiatrists).
INFORMED CONSENT
In electing to take therapy outdoors there emerge certain risks. For example, a common concern
is the ability to protect a client’s confidentiality due to the potential for coming into contact with
other people. Other concerns include the unpredictability of the weather, physical health, or how
the dynamic nature of a therapy encounter may be contained in the outdoors.
Such issues can be addressed at the stage of informed consent, through transparency and
collaboration. Gaining informed consent needs to be a thorough process, involving three important
steps. First, the practitioner and client should discuss the potential for any perceived risks, what
can and cannot be controlled and what the alternatives are to therapy outdoors (e.g. indoor and
digital options).
Second, the client and practitioner can then work together in contracting agreed steps in seeking
to manage or mitigate these risks. For example, these decisions may include, ‘the location for
therapy that would feel most comfortable’, ‘environments or situations that need to be avoided’,
‘how to respond if/when coming into contact with someone that is known to the client or
practitioner’, ‘what would the client like the practitioner to do in this moment?’, ‘how to manage
inclement or changing weather conditions’, ‘what to do if the environment becomes unsuitable
as a session progresses’. In this way, the client and practitioner can negotiate strategic responses
before an event occurs.
Finally, if initial contracting is agreed and therapy outdoors commences, ‘process contracting’
becomes essential. Process contracting involves regularly referring back to the initial contract and
adapting the agreement as new issues arise within the dynamic outdoor environment. Some refer
to this as a ‘mini assessment’ used at the beginning of, or prior to, each therapy session. If at any
point the outdoor therapy begins to feel unsafe for the client or practitioner, without any obvious
resolutions within the contract, therapy should cease or be relocated to another environment
(e.g. indoor or digital).
This collaborative approach assumes a client’s capacity and that election to proceed with therapy
outdoors is one based on autonomy and an explicit shared contracting process, rather than the
client being a passive recipient of therapy.
INTRODUCING PREDICTABILITY
The outdoor context inevitably implies a more unpredictable and less controllable space than
that of the indoor therapy room. However, the sense of containment and controllability can
be enhanced by introducing some elements of predictability within the therapeutic frame.
Examples include:

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• sticking to pre-planned time frames;
• using the same location, route or place to sit;
• selecting environmental features to walk past that can denote the beginning and end
of a session;
• maintaining an agenda;
• a practitioner familiarising themselves with a route or location beforehand, to assess risk,
ensure there are necessary facilities, and identify features in the landscape that could be
incorporated into a session;
• using a private outdoor space;
• using an outdoor space that provides shelter; and
• combining therapy outdoors with other contexts (e.g. indoors and digital).
INCORPORATING THE OUTDOORS INTO THERAPY
PASSIVE VS ACTIVE INCORPORATION
The degree to which the outdoors is incorporated into therapy itself can vary from passive to
active. When incorporated passively, the content of the talking therapy is little different to that
of conventional indoor therapy, with the outdoors simply providing a backdrop. For example,
this may be the case if the outdoors is being used solely for physical distancing purposes during
the Covid-19 pandemic. Alternatively, if the outdoor environment features within the client’s
formulation or is deemed conducive to the therapy goals, there are several ways it can be more
actively incorporated into the talking therapy.
EXAMPLES OF ACTIVE INCORPORATION
Stabilisation, mindfulness and other sensory exercises that use the outdoors to support clients
in feeling safe, contained and grounded in the present moment (e.g. walking whilst paying
attention to the five senses).
Using an outdoor activity to build relationships, social support and/or social competencies
within groups (e.g. sharing vulnerabilities, learning from one another, role-modelling and
systemic observations).
Experiential learning through role play, drama and distancing techniques that allow clients to
experience roles and situations that may be difficult to cope with or recreate in everyday life
(e.g. outdoor fictional adventures and building homes/dens/therapeutic spaces in nature).
Using experiences and achievements in the outdoors to challenge old narratives and build
new ones (e.g. throwing natural objects into a stream to symbolise the throwing away of old
narratives and hiking up a mountain to symbolise strength).

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Observing real-life metaphors as a way of fostering acceptance and self-awareness
(e.g. metaphors that relate human difficulties to uncontrollable dynamics within the natural
world). Metaphors can also be used to internalise the power of nature, building strength and
value-driven behaviour (e.g. metaphors that relate human strengths and values to what can be
observed in the natural world).
Using a client’s interaction with the outdoors as a window into the conscious and subconscious
internal world of the client (e.g. observations of how the client may be feeling or behaving in
a given situation, changes in posture or gait, or in their choice of location or place to sit).
FURTHER CONSIDERATIONS
Practitioners should be aware of relevant local guidance, insurance policies, first aid training
requirements and any permissions required from employers and/or supervisors.
Being away from the therapy room may limit access to available resources (e.g. therapy notes,
computer systems). Practitioners should consider what resources they require during therapy
and ensure that data protection regulations and GDPR are followed.
The respective roles and boundaries within the therapeutic relationship are often reinforced in
conventional indoor settings (formal reception and waiting areas, setup of the therapy room,
choice of clothing, etc.). Outdoor environments could be perceived to pose a significant shift
away from these implicit boundaries. Practitioners should therefore highlight with the client
that their working relationship will remain focused on agreed therapeutic purposes,
with adequate time to explore the feelings and emotions that may arise as a result of changes
in the therapy environment.
Unless dual qualified, most practitioners working with moderate or high intensity encounters
(e.g. outdoor pursuits and adventure expeditions) should be accompanied by qualified outdoor
instructors who are responsible for the activity.
Therapy outdoors also raises the potential for creativity in clinical supervision, such
as supplementing conventional supervision with support from other professionals
(horticulturalists, occupational therapists, outdoor guides, personal trainers, physiotherapists,
sport and exercise psychologists, etc.). It may also be beneficial to hold individual or group
supervision meetings outdoors.

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CONTRIBUTORS
Written by Dr Sam Cooley and Professor Noelle Robertson
(Clinical Psychology Doctoral Training Programme, University of Leicester)
Contributions from:
Association of Clinical Psychologists UK (ACP-UK)
BPS DCP Faculty of Holistic Psychology
The DClinPsy Service User Reference Group (SURG), University of Leicester
Dr Robyn Cooley (Clinical Psychologist)
Dr Jon Crossley (Clinical Psychologist, Director of ACP-UK)
Dr Maria Dale (Clinical Psychologist)
Dr Ceri Jones (Occupational Psychologist and Lecturer in Clinical Psychology)
Dr Arabella Kurtz (Clinical Psychologist and Psychoanalytic Psychotherapist, Director of ACP-UK)
Jane Street (Consultant Clinical Psychologist, Chair of the BPS DCP Faculty of Holistic Psychology)
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