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In a city park, two people walk together – one is talking seriously; the other is listening intently. People stroll past, enjoying the autumn sunshine. It’s not an image that immediately comes to mind when we think about NHS Talking Therapies. We might more typically picture a neutral room with two chairs, or even a couch and a portrait of Sigmund Freud.

NHS Talking Therapies are many people’s first – and often only – encounter with psychological support, in large part because they are free at the point of access and available through primary care services.¹ But some people find the typical therapy setting uncomfortable or even intimidating. The option of outdoor therapy can therefore offer them easier access to the support they need.Ìý

The decision to take therapy into the outside world is not particularly new. In the spring of 1910, Freud famously analysed the composer Gustav Mahler on a four-hour walk through the streets of Leiden, Holland.² Since then, the benefits of access to nature have been widely documented. For example, Roger Ulrich’s groundbreaking 1984 study found that physical health outcomes for hospital patients improved when they could see greenery through a window.³ There is also a body of evidence that confirms the benefits to mental health of exposure to nature, especially while engaging in some kind of physical activity, such as walking.^4,5Ìý

Ecopsychology looks at the relationship between humans and nature – and it has become more popular since the 1980s. It is based on the biophilia hypothesis,⁶ which proposes that humans have an innate tendency to seek connections with the natural world. Consequently, psychological distress increases if we become disconnected from our natural environment.^7Ìý

Ecotherapy, a branch of ecopsychology, harnesses the healing power of nature with a range of therapeutic practices that combine traditional forms of talking therapy with time spent in an outdoor environment, such as walk-and-talk counselling.⁸ Evidence suggests that such interventions not only improve clients’ connections with the natural world but also enhance the experience of therapy. They can support a non-hierarchical relationship between therapist and client, helping clients to talk more freely, especially when they have struggled to engage with talking therapies indoors, online or by phone.^9Ìý

The COVID-19 pandemic prompted therapists to think more creatively and flexibly about clinical settings. Outdoor therapy increased in popularity, in response to pandemic restrictions.¹⁰ Some practitioners, for example, offered walk-and-talk sessions, so they could meet their clients face to face, when indoor working was impossible.¹¹Ìý

The Living Well Consortium consists of more than 40 voluntary, community, faith and social enterprise organisations. The consortium works collaboratively to improve access to mental health and wellbeing services across Birmingham, Solihull and other areas of the Midlands. A large part of this work includes a contract to deliver NHS Talking Therapies.Ìý

In 2021, the Living Well Consortium recruited three qualified counsellors to explore the potential for offering outdoor NHS Talking Therapies sessions. At the time, many clients were requesting face-to-face therapy, but the pandemic restrictions did not always allow for indoor, in-person sessions. The pilot was modelled on the British Psychological Society (BPS) guidance on outdoor therapy.¹² The guidance covers a range of factors, including an assessment of location, practitioner and client suitability, procedures for informed client consent and predictability of sessions, such as a regular meeting place and route.Ìý

The service was also mapped onto Zone 1 of the Institute for Outdoor Learning (IOL) Statement of Good Practice for mental health interventions outdoors, which emphasises that the service’s primary purpose is to provide counselling.^13Ìý

In line with the BPS guidance, the first step was to identify appropriate green spaces to deliver the sessions. The following key features were considered necessary to ensure suitability:Ìý

• even, well-paved paths, suitable for walking and wheelchairs
• an area for practitioners to shelter between sessions, with access to toilet facilities
• availability of benches or seating areas for clients with limited mobility
• adequate links to public transport and/or parking spaces.Ìý

Larger parks in the centre of the city were deemed the most suitable, as they offered easier access to transport options and greater availability of shelter. They were also more likely to have seating areas, as well as wider, well-maintained paths. Parks in the city centre were busier than parks in outlying areas, minimising any concerns about personal safety. But they were also spacious enough to safeguard confidentiality.Ìý

To mitigate the risk of lone working in a public space, the practitioner team created a ‘check-in, check-out’ system on a private WhatsApp group, which was always monitored by at least one practitioner. Counsellors notified the group when they were meeting a client and when the session had finished.Ìý

A new clinical contract was created, based on the BPS guidance for informed consent. The contract:Ìý

• informed clients of the limits to confidentiality when working outside in a public space
• explained that sessions would go ahead, whatever the weather, except if the Met Office issued an alert, in which case the practitioner would contact the client as soon as possible to offer a telephone or video appointment, or to reschedule the session.Ìý

Clients who expressed an interest in outdoor therapy were then booked in for a one-hour telephone assessment with a walk-and-talk counsellor. The telephone assessment discussed presenting issues, goals and expectations for therapy, as well as the implications of working outdoors. Specifically, this included:Ìý

• screening for any health conditions that might impact the client’s ability to move through the space
• assessing the client’s familiarity with the proposed location for therapy, including any personal connections to the place or whether they anticipated seeing anyone they knew
• assessing the client’s positive or negative emotional associations with green spaces outdoors.Ìý

The pilot walking therapy service ran for one year, from November 2021. And it was successful enough to be incorporated as a permanent offer within Living Well Consortium’s choice of NHS Talking Therapies.Ìý

Outcomes were monitored using the PHQ-9 (depression) and GAD-7 (anxiety) questionnaires, which are mandatory for NHS Talking Therapies. We also collected qualitative client feedback – and it continues to inform the ongoing development of the service.Ìý

Mandatory data set monitoring shows that 58% of clients moved to recovery after completing eight to 12 sessions of walking therapy, well above the NHS guideline benchmark of 50% for Talking Therapies. The feedback from clients and the reflections of practitioners highlight the distinctive features of the walk-and-talk offer within an NHS setting.Ìý

‘It was nice compared to being sat in a room for an hour. The experience didn’t feel like therapy.’Ìý

The outdoor setting was particularly appealing to clients who had previously found it intimidating or uncomfortable to meet in a typical practice room. It was also immediately different and separate from their experiences of other professional services. Clients who might have written off counselling, especially clients with negative experiences of other statutory services, therefore had the opportunity to engage with the therapeutic process in a way that might otherwise have been lost or missed.Ìý

Healthcare Counselling and Psychotherapy Journal, October 2024

The practitioners were trained in person-centred experiential counselling for depression (PCE-CfD), as part of the NHS Talking Therapies programme. In their reflections, the counsellors noted that the outdoor setting supported the emphasis on equalising the power dynamic between therapist and client, which is at the core of the Rogerian approach.^14Ìý

‘You feel like you’re making progress with sorting out the issues that are impacting your life and at the same time you’re giving yourself a treat of a lovely walk in a lovely environment.’Ìý

By combining talking therapy with walking, clients can attend to their physical as well as their mental health. A recent meta-analysis shows that increasing our daily step count by just 4,000 can significantly decrease the risk of cardiovascular disease.¹⁵ Many clients also indicated that they would continue to take regular walks, after the sessions had finished.Ìý

‘I often came to the sessions straight from a day of work, and would feel like my mind was at a 100 miles an hour. I found being outside helped me feel a lot calmer by the end of the session, and reduced some of the day’s anxiety.’Ìý

Research into the Japanese practice of shinrin-yoku (forest bathing) documents the psychological benefits of spending time in green spaces, including improvements in depression, anger and anxiety.¹⁶ There are also physiological benefits, such as reduced blood pressure.¹⁷Ìý

Outdoor therapy works at the intersection of physical and mental health, acknowledging the interdependence of these two aspects of wellbeing.^8,9 Walk-and-talk counselling could perhaps be seen as a practical example of the integrated approach, advocated by Doherty and Gaughran, to address co-morbidities in both physical and mental health.^18Ìý

‘I felt there wasn’t the pressure to talk the whole session. I could have moments in which I could just be present and take in my surroundings.’Ìý

Clients often feel the pressure to talk in traditional counselling rooms, as they find silences uncomfortable or a waste of session time.¹⁹ But clients reported feeling less pressure to talk in an outdoor setting. They also felt more present in the moment and their environment. The ability to be present links to Kaplan and Kaplan’s ‘attention restoration’ theory,²⁰ which proposes that natural environments provideÌýtherapy‘soft fascinations’, such as the colours of flowers, swaying of trees or sounds of birdsong. The soft fascinations offer gentle stimulation, but don’t require focus or attention. In contrast, most working and urban environments demand effortful focus and attention that can lead to stress and fatigue. The natural environment can therefore offer relief and enable us to feel restored.

As practitioners, the encouragement of a form of attention that is relaxed and present, rather than goal-oriented, complemented the non-directive approach of PCE-CfD. It might also have helped to support clients who had struggled to engage with the more outcome-focused cognitive behavioural therapy (CBT), which is more widely available within NHS Talking Therapies services.^21Ìý

‘It felt less formal and, in a way, there was less pressure on me … I think perhaps it’s because you’re not sitting in an office staring at somebody but walking along beside them.’Ìý

In an outdoor setting, the therapist walks alongside the client. The lack of eye contact can be helpful for some clients. In the feedback, one client likened the therapeutic encounter to a car journey, when it is easier to talk about difficult feelings because you are not looking directly into someone’s eyes. And in a recent study of walk-and-talk counselling, clients appreciated the release from the expectation to make continuous eye contact with the therapist.^10Ìý

Walking together can foster a ‘side-by-side’ relationship, with client and therapist working collaboratively in attending to both the client’s concerns and the shared environment. Brazier writes: ‘When we go outside, as we actually walk together or sit next to one another, we both experience the same landscape and respond to it, so we can see similarities and differences in how we perceive things.^{’22Ìý}

The consortium originally offered walking therapy to accommodate client demand for face-to-face therapy during the pandemic. But the benefits of outdoor therapy extend beyond the pandemic.Ìý

Some clients find it difficult to engage with therapy in traditional settings, partly as a result of negative associations with medical, clinical and other statutory services. Taking the process outdoors proved a cost-effective way not only to lower barriers to engagement but also to enrich the service.Ìý

During the pilot, we collected quantitative data and qualitative feedback, but no demographic data. Future provision and evaluation of the service would benefit from demographic data, to build a clearer picture of the clients and communities that are best served by the walk-and-talk service, and where it needs to evolve and improve.Ìý

Clients who are not white, middle-class and able-bodied often find it harder to access green spaces.²³ The racialised narratives of nature and belonging in the UK can result in green spaces being both explicitly and implicitly discriminatory.²⁴ Yet, as Djossou argues, outdoor spaces also present counselling and psychotherapy with an opportunity to re-envisage their services, without the lens of white hegemony.²³ Djossou has championed hiking groups, led by black people, to empower participants to feel seen and welcomed into outdoor spaces, a model that could translate well to ecotherapy groups. Living Well Consortium’s Healing Circles, delivered by Pattigift Therapy,²⁵ exemplify another supportive space that directly addresses racial inequality.Ìý

We could also think about developing an outdoor therapeutic experience that does not involve walking, so we could include people who have mobility issues.Ìý

My hope is to encourage further discussion and exploration of outdoor therapy, in order to keep alive the premise of ‘improving access’ that was originally embedded in the NHS Talking Therapies provision.Ìý