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Walking Psychotherapy As a Health
Promotion Strategy to Improve Mental and
Physical Health for Patients and Therapists:
Clinical Open-Label Feasibility Trial
Nicole Koziel, MD, FRCPC
1
, Simone Vigod, MD, MSc, FRCPC
1
,
Jennifer Price, RN, CCN(C), PhD
1
, Joanne Leung, HBSc
1
,
and Jennifer Hensel, MD, MSc, FRCPC
2
Abstract
Background: Persons with mental illness are more at risk for sedentary behaviour and associated consequences. We
assessed the feasibility of outdoor walking during psychotherapy sessions in an outpatient trauma therapy program to
challenge sedentary behaviour.
Methods: In this pilot trial in Toronto, Canada, female therapists and patients >18 years, were encouraged to walk during
12 consecutive trauma therapy sessions. Both groups were provided wearable pedometers. We assessed protocol feasibility
and desirability, and 12-week changes in patient post-traumatic stress [PTSD check-list for DSM-5 (PCL-5)], and depression,
anxiety, and stress symptoms [Depression, Anxiety and Stress Scale (DASS)].
Results: 91% (20/22) of patients approached for the study consented to participate and 17 (85%) completed follow-up ques-
tionnaires. There was walking in 132/197 (67%) of total therapy sessions (mean 7.3 out of 10.9 sessions per participant).
Inclement weather was the predominant reason for in-office sessions. At 12-week follow-up, PCL-5 mean scores decreased
from 38.4 [standard deviation, ((SD) 11.8) to 30.7 (SD 14.7)], [mean difference (MD) 7.7, 95% CI: 1.5 to 13.8]; 41% (7/17)
participants had a clinically significant PCL-5 score reduction of >10 points. DASS-stress mean scores decreased from 19.0 to
16.0 (MD 3.0, 95% CI: 0.3 to 5.6). No changes were observed for DASS depression (MD -0.9, 95% CI: −5.1 to 3.3) nor DASS
anxiety (MD -0.2, 95% CI: −3.1 to 2.7). Daily step reporting was inconsistent and not analyzed. There was high acceptability
amongst patients and therapists to walk, but not to record daily steps. There were no adverse outcomes.
Conclusions: It was feasible and acceptable to incorporate outdoor walking during trauma therapy sessions for patients and
therapists. Weather was the greatest barrier to implementation. Further randomized-control study to compare seated and
walking psychotherapy can clarify if there are psychotherapeutic and physical benefits with walking.
Keywords
post-traumatic stress disorder, walking, psychotherapy, mental health, exercise
Childhood interpersonal trauma –exposure to events that
threaten a child’s physical and psychological safety–increases
risk for mental illness and cardiovascular disease.
1
Integrating
walking into psychotherapy is a novel opportunity to improve
cardiovascular risk factors and symptoms of mental illness,
support emotion regulation, facilitate therapeutic alliance
and integration of therapy skills, and habitualize walking.
2
We evaluated the feasibility of integrating walking into
outpatient trauma-focused psychotherapy in an open pilot
trial.
1
Women’s College Hospital, Toronto, Ontario
2
University of Manitoba, Winnipeg, Manitoba
Corresponding Author:
Nicole Koziel, Women’s College Hospital, 76 Grenville St, Toronto, ON, Canada, M5S 1B2.
Email: nicole.koziel@wchospital.ca
Research Letter
The Canadian Journal of Psychiatry /
La Revue Canadienne de Psychiatrie
1‐3
© The Author(s) 2021
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/07067437211039194
TheCJP.ca | LaRCP.ca
We aimed to enroll 20 participants (age 18 +years) receiv-
ing or waitlisted for individual psychotherapy in a hospital-
based trauma therapy program in Toronto, Ontario with a
predominantly female patient population (∼94%).
3
Potentially
eligible participants were sequentially approached for the
study by participating MSW/RN/PhD/MD-trained therapists
(five of the program’s 13 therapists participated, to target
∼4 participants/therapist). Research staff assessed eligibility.
Individuals screening positive on the Physical Activity
Readiness Questionnaire required medical clearance from
their primary care providers. Weekly sessions followed Judith
Herman’s staged model of building safety and skills before pro-
cessing traumatic memories in depth.
4
While the therapy is not
manualized, a relational therapy frame is followed by all
program therapists to a maximum of 26 weekly 45−50 min ses-
sions. Study sessions were held outdoors whenever possible, on
well-maintained paths in a nearby city park. An advanced car-
diovascular practice nurse led a 1-h therapist training session
on safe walking practice prior to the study.
The primary outcome was protocol feasibility: recruitment
and retention rates, proportion of sessions walked (and
reasons not walked) and participant and therapist acceptability.
The pilot was to be considered successful if 20 participants were
recruited, and walking occurred the majority (>50%) of total
sessions. The first five participants and four non-investigator
therapists provided interim feedback via separate focus groups
midway through the study. All participants and therapists
were asked to provide narrative written feedback in response
to specific questions at study completion. Clinical outcomes
at 12-weeks post-enrollment were the PTSD checklist for
DSM-5 (PCL-5) and Depression, Anxiety, and Stress Scale
(DASS). A Fitbit Alta
TM
and daily step logs were provided
to participants to record their activity. The Women’sCollege
Hospital Research Ethics Board approved the study
(#2017-0040-B).
From 22 patients approached and meeting eligibility criteria
from October 2017 to October 2018, 20 consented and 17
(85%) completed follow-up questionnaires. Mean age was 46.3
years (±10.6, 100% female), with clinically significant PTSD
symptoms (mean PCL-5 =39.5 ±11.8) and mild-to-moderate
mean DASS-depression (13.8 ±8.0), DASS-stress (18.7 ±9.2)
and DASS-anxiety (8.8 ±5.2) scores. About 60% (n=12) had
low-moderate baseline physical activity (International Physical
Activity Questionnaire –short form). Walking occurred for
132 of 197 (67%) total therapy sessions. The mean number of
sessions walked was 7.3 (range 3–11) out of 10.9 mean sessions
per participant. Weather accounted for 35 (58%) of non-walking
sessions, illness/injury for 15 (23%), and feeling too upset to
2The Canadian Journal of Psychiatry
walk for 5 (7.7%). Other reasons occurred <3 times (tired, late,
needing to eat, paperwork review and therapist illness).
Participant and therapist acceptability was high; the fluidity of
the therapeutic frame introduced by walking outside the office
setting was not felt to negatively impact progress. There was
meaningful feedback –including that participants found daily
step log completion burdensome –andnoadverseevents
(Figure 1).
At 12-week follow-up (n=17 participants), PCL-5 mean
scores decreased from 38.4 (SD 11.8) to 30.7 (SD 14.7),
[mean difference (MD) 7.7, 95% CI: 1.5 to 13.8]; 41% (7/17)
participants had a clinically significant PCL-5 score reduction
of >10 points. DASS-stress mean scores decreased from 19.0
to 16.0, (MD 3.0, 95% CI: 0.3 to 5.6). No changes were
observed for DASS depression (MD -0.9, 95% CI: −5.1 to
3.3) nor DASS anxiety (MD -0.2, 95% CI: −3.1to2.7).
Daily step reporting was inconsistent and not analyzed.
The study results suggest that walking during psychother-
apy is well tolerated in this population, with symptom improve-
ments in the desired direction. We could not quantitatively
assess changes to participants’overall level of physical activity,
but participants qualitatively reported an increase in non-
sedentary behaviour. These results are consistent with those
of a small study of older, hospitalized patients with depression,
5
but minimal research has been done in this area for ambulatory
patients, so the current study is novel. Limitations were the all-
female participant and therapist population, high baseline activ-
ity levels of 40% of participants and that one investigator was
an intervention-provider. Generalizability to settings where a
proximate, safe, outdoor walking space is not as readily avail-
able is a consideration and options for indoor walking are likely
needed for cold and rainy climates. Finally, with a small sample
size and no control group, the focus was on feasibility of the
model and not efficacy for mental and physical outcomes,
including how the depth of the therapy compares to that of
office-based settings. Incorporating this pilot’s learnings, a
future randomized controlled trial could aim to answer these
important questions.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This work
was supported by the Women’s College Hospital Academic and
Medical Services Group/Association of Fundraising Professionals
Innovation Fund.
ORCID iDs
Nicole Koziel https://orcid.org/0000-0002-8027-0494
Jennifer Hensel https://orcid.org/0000-0003-4194-6049
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Koziel et al. 3
