In this article, I invite readers to consider the potential of outdoor therapies and to think about what it would mean to step outside with a client, engage with the natural environment, library picture, for illustration and to embrace an element of adventure within the therapeutic process. I’m not suggesting that every counsellor should pack up a rucksack and head out for the hills with their clients. As with all therapeutic approaches, careful consideration should be given to exploring the questions: ‘Why this approach?’, ‘Why with this client?’ and ‘Why now?’.
This article will offer insight into the potential benefits and applications of outdoor approaches that draw upon the restorative power of forests, beaches, parks and other landscapes. However, I also hope to dispel some of the idealistic notions that can be attributed to working outdoors with a client and to consider the practicalities that impact upon the therapeutic relationship, to help practitioners make informed and ethical decisions about outdoor approaches.
Unbinding binary assumptions
Before diving into the field of outdoor therapies, let’s first pause to acknowledge some of the binary assumptions that are sometimes surmised from the names attributed to this practice. The provision of four walls is thought to afford safety, containment, confidentiality and professionalism; all ways in which the indoor environment has become synonymous with the therapeutic frame.1 Outdoor therapy can be posed in opposition to indoor therapy, alluding to a practice which may be thought of by some as ‘other’, ‘alternative’ or possibly even ‘radical’. Cooley et al’s recent study captured organisational perspectives on outdoor talking therapy, noting that practitioners often have fixed preferences for the therapy environment and rarely explore the possible benefits of alternative environments or consider involving clients in the decision-making process.2
However, there is a well-established and ever-growing body of evidence informing us of the physical and psychological risks to our increasingly indoor and sedentary lifestyles, factors which have been compounded by the COVID pandemic.
It may be time to review what environments are best suited to our clients’ wellbeing and to their perception of a therapeutic space, having spent the best part of two years under lockdown. Consequently, Cooley et al encourage practitioners to adopt a position of ‘environmental safe uncertainty’; to be curious, open-minded and collaborative in exploring therapeutic environments.2 In fact, Cooley et al suggest that being dynamic and open-minded can increase access and engagement with therapy for some populations.2 The increasing prevalence of mental health difficulties in higher education students, and the possible aggravation of poor mental health throughout the pandemic require critical attention to understand the demographic needs and to consider innovative interventions and frameworks. The need to improve the mental health of students and encourage better states of wellbeing through adaptable and emerging interventions has been highlighted by Universities UK.3 In 2011, Kyriakopoulos piloted an Adventure Therapy Project with higher education (HE) students, who self-reported enhanced intrapersonal relationships and improved interpersonal relationships, and identified the outdoor environment as useful for providing an experiential, secure place for achieving inner healing.4
It is therefore important during this shifting moment in society to reassess binary or taken-for-granted notions of the therapeutic environment and approaches that may work for clients and to embrace a dynamic approach towards working environments. However, in this article I argue that there is more to outdoor therapy than a change in the backdrop and that it is important for practitioners to engage with the ongoing philosophical and theoretical themes within the literature in order to achieve an integrated approach to outdoor therapy.
Understanding a field with many names
There are multiple names which have been coined for therapeutic approaches that utilise the outdoors, the natural environment and adventure, such as: ‘nature-based therapy’, ‘wilderness therapy’, ‘eco therapy’ or ‘walk and talk’ therapy (to name a few) This rich, diverse and idiosyncratic field of practice draws upon interdisciplinary sources from experiential education, psychotherapy and outdoor education. Practitioners may be encouraged to consider being part of a dynamic multi-modal practice while also questioning where their philosophical stance fits into the wider field of practice. Two distinctions that can be useful to note are the use of the natural environment and the use of adventure:
The natural environment: within this spectrum of approaches, practitioners may emphasise the restorative benefits of being outside or of physical exercise as a central therapeutic ingredient, or they may work to use nature-based therapeutic tasks, drawing on the rich metaphors of life processes observed in the natural environment.
Adventure: under this term, practitioners emphasise meaningful engagement with activities, novel environments and an element of journeying as the central therapeutic ingredient. Reflection upon the individual or group engagement in activities can provide experiential fodder for understanding behaviour, group dynamics and process.
Adventure, journeying and the wilderness
These words may raise some eyebrows within the counselling and psychotherapy community. Questions may arise as to how physical or psychological risk impact upon the therapeutic process. As Michael Gass in the US constructively queries in his seminal text on adventure therapy: ‘How can dangling off a cliff be therapeutically relevant?’.5
However, there is a rich and growing evidence base for the therapeutic use of adventure that has formed since the 1960s, when modern adventure programmes and journeys started to be used for therapeutic populations. The triennial International Adventure Therapy Conference (the ninth will be held in Norway in June 2022) showcases the vast research and practice which is happening across the world. In the UK, it is important to note that there are national governing bodies and professional qualifications for leading adventurous activities such as canoeing, climbing, caving and hill walking (all of which could be used as a therapeutic vehicle). Practitioners interested in the use of adventure activities should seek the appropriate training, insurance and outdoor-specific first aid course. While being aware of relevant standards, we must also have a rationale for the use of such activities within the therapeutic process and be aware of the metaphoric and therapeutic value that we can tap into, no matter how big or small the adventure is.
Adventure is a journey with an uncertain end, a quest to find out more than we already know about the world around us and about ourselves, and a commitment that extends from the planning and packing phase right through to the point at which we decide to end the journey. For many young people, going to university or college might be the biggest and bravest adventure they have yet embarked upon – there may be much they have to learn about themselves and the way they approach life. Adventures take a commitment to achieve a goal, but they are often challenging, the process may not be straightforward, and bad weather may need to be endured. While university or college presents an exciting transition into adult life, it can also present academic, social, and financial pressures.6 Adventure can teach us how and when to consult our maps when we get lost, how to reroute or accept when obstacles get in the way of goals, and how to connect with the inner strength we carry. If we accept that these elements are part of our work with all clients, maybe we could consider that we are all adventure therapists to some degree.
‘The natural environment’
The therapeutic value of nature has been recognised by the earliest indigenous cultures and was explored by some of the forefront researchers of modern psychotherapy: Freud, Jung, Rogers, Perls and Erikson (read Chandler for a detailed exploration of the connections these individuals have with the natural environment).7 ‘Fertile ground exists for contemporary therapists to acknowledge their own theoretical roots, and to grow practices that integrate relationships with our wider nature.’7 Despite this, awareness of relationships with wider nature plays little, if any, part in counselling training. In the UK, therapy training predominantly prepares counsellors and psychotherapists to work with individuals in indoor settings. Therapists are increasingly attempting to respond to the challenges of our times, such as the lack of contact with nature and the relationship of our psyche to environmental destruction. In response, outdoor therapies and ‘green prescriptions’ may offer a way to welcome a relationship to the environment into therapy. Further nature-based interventions are framed as an alternative treatment that can alleviate the strain on the health and social care systems in the UK, which have been struggling with budget cuts since the recession and which we might predict, given the current pandemic, may be under strain once again.
There are several theories which support the notion that the natural environment is important for human health, functioning and wellbeing. The biophilia hypothesis,8 psycho-evolutionary theory9,10 and attention restoration theory11 are three foundational theories which have prompted further empirical research. It could be useful to explore our innate emotional affiliation with other living organisms and the impact of having become surrounded by technological developments and urban settlements on our sense of identity and mental health.8
Richard Louv coined the term ‘nature deficit disorder’ to describe the impact of denying children the opportunity to form an attachment with their natural ecosystem.12 There is also evidence which highlights the positive response to views of nature and the reduction in stress linked with the limbic system, which can have significant effects on our health and ability to recover from illness.9
Next in this issue
Contact with nature helps to restore the capacity to concentrate as it offers a break from the fatiguing stimuli, and can provide fascination through both engaging activities (when we do something so engrossing that we can suspend ourselves from our internal dialogue, for example mountain biking) and through effortless endeavours (when there is space for the mind to wonder, for example watching moving water). The importance of time spent in the natural environment for FE and HE students could be vital to combat the increasingly digital and media-saturated climate we live in (read Bragg and Atkins13 and McGreeney14 for some useful summaries of the supporting evidence for nature-based interventions).
These three theories form the basis for the intrinsic benefit that is expected from nature-based interventions, and are described as ‘passive’ as they are at play as soon as someone is in contact with the natural environment and do not require enhancement or intervention from a practitioner. Research has demonstrated the shift in the therapeutic alliance that occurs when working outdoors and the emergence of a tripartite therapeutic partnership between client, nature and therapist, where each can be affected by the others.15 The role of the therapist becomes the ‘witness, container, and mediator’16 or the ‘partner’.17 The way in which practitioners frame an outdoor experience can also have a big impact. For example, whether practitioners philosophically consider the engagement with nature as an ‘escape’ (escaping from urbanised and fast-paced daily lives) or a ‘return’ (returning and reconnecting to the natural environment) can have an impact on how the therapeutic work may be contextualised in the outdoor environment.
Impact on the use of ‘self’
We often talk about offering our authentic selves to clients as the base of a genuine therapeutic relationship. So, it might be interesting to consider how our working environments inform, feed and support our sense of self. Possibly, affirmations come from the clothes we wear, the rituals or habits formed when preparing for a client to come through the door, the set-up of the client room and inviting positioning of chairs. From my research with outdoor therapists, one theme that stood out is the practitioner’s ability to feel more attuned with their authentic self within outdoor environments. The connection with natural environment and the pace of physical and embodied movement feed the practitioner’s sense of attunement with the present moment:
‘I notice that when I’m outside I can be more immediate with what is going on in the moment, I can be more focused, perhaps more available for the client’.18
When considering how we offer our best selves to the client, how we look after ourselves and our capacity to hold the client, it seems healthy that therapists may want to have the option of stepping beyond the realm of the office. Equally, before offering this type of work, practitioners may reflect on their level of competence and personal comfort with a range of outdoor environments and environmental conditions. Can we ensure both psychological and physical safety for a client who embraces a walk and talk session on a cold and rainy day, or pushes themselves too far? What other ‘hats’ do we need to be wearing in order to keep an eye on these aspects: navigator, first aider etc?
Process, embodiment and movement
Embodiment describes an active dimension combining sensory and bodily engagement with the lived experience.19 From intimate interactions with the embodied experience, sensual and cognitive epistemologies can be explored.20 Understanding the embodied experience can provide a holistic perspective to the therapeutic relationship. Corazon et al suggest that sight, smell, sound, tactile stimulation by vegetation, wildlife and elements can enrich bodily senses.21
The altered physicality of working outdoors has been reported to impact the therapeutic experience in a variety of ways. It offers nonverbal synchronicity between client and therapist;22 contributes to a greater abstract conceptualisation;23,24 increases thought processes ,which can loosen stuck thinking and forge new connections between different concepts;25 and can exaggerate passions, mystical experiences and sensory appreciation.26 A participant I researched described the ways of experiencing a client’s inner world through observation of their engagement in the activity:
‘He chose a route through some woodland paths and ended up going off track and over walls… it was almost quite playful, and quite a sense of lostness and re-emerging and all that kind of stuff he was experiencing, which mirrored some of our indoor sessions, literally as opposed to metaphorically’.17
Outdoor therapies can create tangible, embodied and external references for the therapeutic relationship. Without the frame of a physical room, other rituals are created to transition into the therapeutic space. The lighting of a fire is one such ritual that often occurs and presents a different dynamic for the client and practitioner to negotiate: who will take responsibility? And how will agency, autonomy and support be enacted? There is opportunity to learn together, feeding the fire and letting it build strength.
In such instances, the client and therapist become a team and the consequences of actions shared. Where the client takes the lead, the therapist can sit with the client, trusting in their ability to light the fire, even when it takes time to successfully strike a flame and light the tinder. Unconditional positive regard, acceptance of failures and quiet companionship can all be communicated with more immediacy than that which is usually communicated in the counselling room. The metaphors often appear to run deeper; the strength of the fire reflecting and building as the therapeutic alliance deepens; the result of boiling water a tangible reference to the shared and mutual collaboration.
Ethical practice has not always been assured in adventure therapy programmes. In the early 2000s, there were a number of deaths and reports of unethical treatment in American youth residential services, resulting in government action. It is still deemed legal in some states for parents to send children to treatment without the child’s consent or input (or in some cases against their will) and through transportation services which forcibly remove children from their homes.27,28 In the UK, there may be a range of professionals working therapeutically with clients in the outdoors with varying levels of outdoor-specific and therapy-specific training and qualifications. This can present a rich diversity within the field, however Harper et al recognise that different professionals are governed by different codes of ethics and operating standards, and in some cases, qualifications which do not correspond to a particular ethical framework.28 A recent publication from Richards et al offers an attempt to understand the intersection of professionals within the field with the ‘Outdoor Mental Health Invention Model’, which encourages practitioners to communicate different types of practice in reference to the various ‘zones’.29
While BACP practitioners value informed consent and acting in the best interests of the client, it is important to consider how situations may change with a client while outdoors, what appropriate levels of anxiety might look like in the context of a therapeutic relationship,30 and what we would do if a client wanted to stop participating during an outdoor experience. Counsellors and psychotherapists may therefore be advised to understand the development of ethical guidelines from allied disciplines such as experiential education, psychology and health and to recognise some of the discipline-specific models and theories which exist for ethical decision-making.31–34 Furthermore, it is important for research and practice to promote routine outcome monitoring and to regularly check if the approach is having the desired impact on our clients’ lives.35
In the wake of the pandemic, more and more counsellors have taken their work outside. It is important for practitioners to consider if this is a temporary adjustment to maintain contact with clients through lockdown restrictions or if this will become a more permanent service they offer. I hope this article has given some ideas on how you can extend your philosophy of working outdoors and offering therapeutic adventures.
Some issues to consider when working outdoors/using adventure therapeutically:
- Does going outside move away from the therapeutic task or provide opportunity to deepen and explore some aspects together?
- What fears and concerns might the client have about going outdoors?
- What is the client’s relationship with nature/the natural environment? What role has it played in their life so far and could it become an additional therapeutic tool?
- How might it change your work/alliance to work outside/use adventure?
- Have you included details on outdoor therapy and the potential risks in your contract and during your verbal contract?
- Will it affect your policies, procedures and risk assessments?
- Will it affect the timings and costs of the service?
- Does it affect the accessibility and inclusivity of your practice?
- What conditions are required for you and your client to feel safe to explore that which the client wants to bring to the session?
- What will you do if you encounter other outdoor users/familiar people? You may wish to say something like: ‘I’m in the middle of something, we’ll catch up later’.36
- When and where does the session begin and end when there’s no waiting room, no clock on the wall.
- How will you arrive at the destination? If together, do you have vehicle insurance? If separate, what is the backup plan should the client’s transport not work out? How remote is the location – how long is it to the nearest facilities and emergency services?
- Are you competent and qualified to be doing the activity with the client?
- Do you have appropriate insurance cover?
- Are you carrying a first aid kit and emergency phone, and have you made your client aware of this?
- Have you considered personal hygiene/toileting arrangements?
- Have you told somebody where you are going and what time you expect to return?
I'm out of the office - BACP Workplace, 2021
1. Jordan M, Marshall H. Taking counselling and psychotherapy outside: destruction or enrichment of the therapeutic frame? European Journal of Psychotherapy and Counselling 2010; 12(4): 345–359.
2. Cooley SJ, Jones CR, Moss D, Robertson N. Organizational perspectives on outdoor talking therapy: towards a position of ‘environmental safe uncertainty’. British Journal of Clinical Psychology 2021; 61(1): 132–156.
3. Universities UK. Stepchange: Mentally Healthy Universities. [Online]. https://www.universitiesuk.ac.uk/sites/default/files/field/downloads/2021-07/uuk-stepchange-mhu.pdf#page=12 (accessed 9 September 2021).
4. Kyriakopoulos A. How individuals with self-reported anxiety and depression experienced a combination of individual counselling with an adventurous outdoor experience: a qualitative evaluation. Counselling and Psychotherapy Research 2011; 11(2): 120–128.
5. Gass M. Adventure therapy: therapeutic application of adventure programming. Colorado: Association for Experiential Education; 1993.
6. Hunt J, Eisenberg D. Mental health problems and help-seeking behavior among college students. Journal of Adolescent Health 2010; 46(1): 3–10.
7. Chandler S. Counselling and psychotherapy outdoors: grounding our practice in our theoretical roots. In: Norton C, Carpenter C, Pryor A (eds). Adventure therapy around the globe:
international perspectives and diverse approaches. Illinois: Common Ground Publishing; 2015 (pp45–57).
8. Wilson E. Biophilia. Cambridge MA: Harvard University Press; 1984.
9. Ulrich R. View through a window may influence recovery from surgery. Science 1984; 224: 420–421.
10. Ulrich R. Effects of gardens on health outcomes: theory and research. In: Marcus C, Barnes M (eds). Healing gardens: therapeutic benefits and design recommendations. Chichester: Wiley; 2000 (pp27–86).
11. Kaplan R, Kaplan S. Restorative experience: the healing power of nearby nature. In: Francis M, Hester R (eds). The meaning of gardens. Cambridge MA: MIT Press; 1990 (pp238–243).
12. Louv, R. Last child in the woods. London: Atlantic Books; 2005.
13. Bragg R, Atkins G. A review of nature-based interventions for mental health care. Natural England Commissioned Reports, 2016; 204.
14. McGeeney A. With nature in mind; the eco therapy manual for mental health professionals. London: Jessica-Kingsley; 2016.
15. Hegarty, J. Out of the consulting room and into the woods? Experiences of nature-connectedness and self-healing. European Journal of Ecospychology 2010; 1: 64–84.
16. Berger R. McLeod J. Incorporating nature into therapy: a framework for practice. Journal of Systematic Therapies 2006; 25(2): 80–94.
17. Shingler (Schwenk) H. Outdoor therapy: an interpretative phenomenological analysis examining the lived-experience, embodied, and therapeutic process through interpersonal
process recall. Sports 2019; 7(8): 182.
18. Shingler (Schwenk) H. Outdoor therapy: an interpretative phenomenological analysis examining the lived-experience, embodied, and therapeutic process through interpersonal process recall. Unpublished master’s thesis. University of Worcester; 2017.
19. Humberstone B. Embodiment, nature and wellbeing. In: Robertson M, Lawrence R, Heath G (eds). Experiencing the outdoors: enhancing strategies for wellbeing. Boston: Sense Publishers; 2015 (pp61–72).
20. Brown M, Heaton S. Ko ahau te awa ko te awa ko ahau – I am the river, and the river is me. In: Robertson M, Lawrence R, Heath G (eds). Experiencing the outdoors: enhancing strategies for wellbeing. Boston: Sense Publishers; 2015 (pp49–60).
21. Corazon S, Schilhab T, Stigsdotter U. Developing the therapeutic potential of embodied cognition and metaphors in nature-based therapy: lessons from theory to practice. Journal of Adventure Education and Outdoor Learning 2011; 11(2): 161–171.
22. Revell S, McLeod J. Therapists’ experience of walk and talk therapy: a descriptive phenomenological study. European Journal of Psychotherapy and Counselling 2017; 19(3): 1–23.
23. Barsalou L. Grounded cognition. Annual Review of Psychology 2008; 59(1): 617–645.
24. Niedenthal P, Barsalou L, Winkielman P, Krauth-Gruber S, Ric F. Embodiment in attitudes, social perception, and emotion. Personality and Social Psychology Review 2005; 9(5): 184–211.
25. Leung A, Kim S, Polman E, Ong L, Qiu L, Goncalo J, Sanchez-Burks J. Embodied metaphors and creative “acts”. Psychological Science 2012; 23(5): 502–509.
26. Thrift N. Non-representational theory: space, politics, affect. London: Routledge; 2008.
27. Tucker AR, Combs KM, Bettmann JE, Chang TH, Graham S, Hoag M, Tatum C. Longitudinal outcomes for youth transported to wilderness therapy programs. Research on social work practice 2018; 28 (4): 438–451.
28. Harper N, Rose K, Segal D. Nature-based therapy: a practitioner’s guide to working outdoor with children, youth and families. US: New society publishers; 2019.
29. Richards K, Hardie A, Anderson N. Outdoor mental health interventions and outdoor therapy: a statement of good practice. UK: Institute for Outdoor Learning. [Online.] https://www.outdoor-learning.org/Portals/0/IOL%20Documents/Outdoor%20Mental%20Health/Outdoor%20Therapy%20Statement%201.3%20-%2012%20Oct%202020.
pdf?ver=2020-11-09-101048-717 (accessed 1 December 2019).
30. Gabrielsen LE, Harper NJ, Fernee CR. What are constructive anxiety levels in wilderness therapy? An exploratory pilot study. Complementary therapies in clinical practice 2019; 37: 51–57.
31. Gass M, Gillis H, Russell K. Adventure therapy: theory, research and practice. New York: Routledge Taylor and Francis Group; 2012.
32. Natynczuk S. Adventure therapy deconstructed: a journey towards the good enough practitioner and professional practice. [Online.] https://sparekrab.com/wp-content/uploads/2019/12/ATE-Adventure-Therapy-Deconstructed-A-Journey-Towards-Professional-Practice.-.pdf (accessed 1 December 2019).
33. Becker S. Wilderness therapy: ethical considerations for mental health professionals. Child and Youth Care Forum 2010; 39(1): 47–61.
34. Revell S, Duncan E. Cooper M. Helpful aspects of outdoor therapy experiences: an online preliminary investigation. Counselling and Psychotherapy Research 2014; 14(4): 281–287.
35. Dobud WW, Cavanaugh DL, Harper NJ. Adventure therapy and routine outcome monitoring of treatment: the time is now. Journal of Experiential Education 2020; 43(3): 262–276.
36. Jordan M. Nature and therapy: understanding counselling and psychotherapy in outdoor spaces. London: Routledge; 2015.