Psychotherapy in Nature: Exploring an Alternative Psychotherapeutic Framework to Address the Limitations of Working in Traditional Settings in Order to Move with the Times

Abstract

This paper introduces nature therapy and single session therapy as alternative psychotherapeutic frameworks in addition to more traditional ways of working, offering a modern perspective on evolving societal and individual needs. In particular, the concern for human coping mechanisms and survival in today’s fast paced environment dictates a growing need to address conflicts of inner and outer lived experiences, dissociation, and trauma, where traditional settings are failing or inadequate. Ethical considerations and applications for working outside in nature are discussed, as well as limitations for traditional settings. This paper can be used as an introductory guide for practitioners seeking to work therapeutically in nature.

1. Introduction

Traditional room-based psychotherapy has come a long way since the nineteenth century, however, psychodynamic approaches and therapeutic traditions have maintained their place in the psychotherapy field to this day. One of the better-known paradigms that psychotherapy training courses still use as a core element and foundation to their teaching, is humanism, and the work of psychologist, Carl Rogers. In the 1950’s Roger’s created a person-centred/client-led psychotherapeutic framework that included ‘Core Conditions’, which he deemed as necessary in order for the psychotherapy to be effective [1]. Decades later, plentiful scientific research has supported this notion, and understandably this framework still forms an important part of many psychotherapy exchanges around the world.

Roger’s core conditions of ‘empathy, congruence, and unconditional positive regard’ form part of the second foundational aspect of a safe and effective psychotherapy framework, which is the importance and strength of the relationship between therapist and client [1]. Generally speaking, this humanistic approach forms the underpinnings of many newer modality frameworks, and lends itself to being adaptable to other frameworks based on the evidence-based effectiveness of its principles. Furthermore, the neurobiological aspects of humanism are poignant when considering a non-cartesian, embodied approach in nature, which considers the whole of the person as opposed to separating mind and body. For that reason, throughout this chapter, it can be assumed that any nature therapy discussions or examples are being referred to as within the context of a humanistic approach.

Nature therapy shares many aspects of humanism, and at its core is the parallel notion that clients seeking therapy do so in a state of incongruence, thus the therapeutic intervention can restore the client to a state of congruence. Additionally, humanism and nature therapy share important understandings of human existence, not least of all that we are all interconnected to one another, our internal and external environments and their processes, and indeed nature itself. In this chapter we will consider some alternative ways for working with clients outside in nature, within the context of a therapeutic framework.

2. Characteristics of traditional psychotherapy frameworks

Generally, most traditional psychotherapeutic frameworks are based on the following: initial engagement in an assessment or screening with the service to determine whether the service/practitioner is right for them and their struggles; agreeing a set amount of sessions relevant to budget or necessity for improvement, determined at assessment stage, e.g. time-limited (perhaps 6–20 sessions) or open- ended work (as many sessions as required, which may be years); thereafter, client and therapist working within a room-based setting that usually has two comfortable chairs and engaging in talking therapy; on average, meeting once or twice weekly for 50–60 min; in an ideal situation, upon completion of the work, agreeing and planning on working towards a suitable and safe ending session.

It must be acknowledged that there are of course variations to the above, but in general, that is what a traditional framework depicts. Along with the theory briefly mentioned above, the common features of the psychotherapy framework have changed very little since the 1950’s, which understandably, in our evolving society, leads us to notice where this framework may not work for certain individuals, groups or presentations today.

One of the most salient research areas of psychotherapy, is the therapeutic relationship and its positive correlation with effectiveness. It has been argued that for this relationship to have a meaningful or positive impact on the therapeutic experience of the client, there must be more than one session. However, it is also evidenced that Roger’s core conditions alone impact the effectiveness of psychotherapy. Consequently, it could be suggested that there is a platform for an alternative framework in the form of a single, one-off session, so long as the core conditions are present.

2.1 Single session psychotherapy

Single session therapy (SST) is not a new concept. In Ref. [2] Dryden documents that both Freud and Adler had used a single session approach in the late 1800’s and early twentieth century. Over the last two centuries, it could be understood that its use evolved out of a common experience a lot of therapist’s encounter; which is that often clients will only ever attend one session. It can be for a number of reasons, but not least of all recognising they are not ready to engage in ongoing therapy sessions. As a consequence, Moshe Talmon published work on the ‘effect of the first (and often only) therapeutic encounter’ which opened up opportunity to explore how a single session could be used to maximum benefit, whilst also considering the evidence base for distinct features of a psychotherapy framework, such as a pre-assessment session, establishing and utilising the therapeutic alliance, goal setting, therapeutic process, and a safe, pre-planned ending. One of the contraindications of SST is the suitability or effectiveness of a single session for certain presentations, such as PTSD or attachment disorders. That said, there are also benefits that may address downfalls of a traditional framework, understanding that not one size fits all. The most obvious benefit of SST is that it allows the client autonomy to choose as and when they want to engage in a therapeutic encounter; and additionally, an affordable and manageable way of accessing therapy without time or financial constraints. Furthermore, as evidence suggests, SST is effective, despite the assumptions traditional thinkers may purport. That said, it is important to note that SST is not a modality in itself, but more a way of working that can be adapted and used alongside other existing frameworks. As will be discussed further in this chapter, SST lends itself to complimenting a nature therapy framework.

2.2 Nature therapy as an alternative intervention

Nature therapy, also known as ecotherapy or nature assisted psychotherapy, is driven by a social constructivist worldview. It takes the position of understanding that we are not separate to the environment or other systems inside us or around us. For example, our internal biological system is not separate to our neurological system; and we are not separate from the functions of our external work place, families and relationships, or indeed the processes and systems of nature. In understanding that we are not separate from our environment, nature therapy provides the opportunity to explore our relationship with nature, and the meanings that it may have as a parallel to the relationship we have with ourselves.

When referring to nature within this chapter, it will be relating to the outdoors in any form of green space; beach, forest, garden, water, etc. Furthermore, as will be discussed later on, whilst nature is typically found outdoors, working in a nature therapy framework can also include bringing nature indoors, or interacting with it inside, for example: listening to nature sounds; bringing plants/planting inside; working with sand; holding a rock or a leaf in your hand.

Nature therapy can take a wide variety of contexts and approaches, including horticultural and group projects, or sitting on a beach and talking with the therapist. As the area is so broad, for the purpose of this chapter, nature therapy will be referred to in the context of a psychotherapeutic framework, as opposed to social/community experiences or projects, and will include both the outdoor and indoor setting. Furthermore, it is important to note that there are currently no advanced or singular, evidence-based nature psychotherapy frameworks, and so this too, can be thought of like SST, in that it is an approach rather than a modality that can be used and developed alongside existing frameworks.

2.3 Limitations to traditional room-based, talking therapy frameworks

General presentations such as anxiety and depression can be easily and effectively addressed within the therapy room. The therapy room can feel like a safe and containing space to many individuals, couples, families, and groups. That said, even in these instances, depending on age and gender, a barrier to starting this type of therapy may be stigma and managing to engage with the service in the first place. For example, there is plentiful research literature that supports the concept that men, in particular are less likely to engage in traditional room-based psychotherapy, as well as young people, due to societal judgements and pathologizing attitudes that suggest ‘you may be mad’ or ‘weak’ if you are having counselling or psychotherapy. Organising and attending an appointment outdoors in nature at the beach, forest, or botanical garden can remove the potential and fundamental challenge of overall and initial engagement relating to stigma, and often presents as less formal and therefore not intimidating and clinical.

In thinking about the types of difficulties clients might face and where room-based settings may not work or indeed be suitable for the client, post-traumatic stress disorder (PTSD) or psychological trauma of any type is a great example. When a person experiences trauma, whether it is a one-off event or prolonged experience, afterwards, it often leaves the body in what we would call a hyper-vigilant state: the brain is telling the nervous system to constantly be ready for oncoming threats, and as such, similar or other environmental cues can trigger the brain into the primal survival response of fight, flight or freeze. In my clinical experience, it is most common that individuals seeking therapy for trauma related difficulties can find being shut in a small room with another person very triggering. By that, I mean their nervous system can perceive that setting as a threat. Often the notion of being trapped inside a room and not being able to ‘flee’ (flight) when triggered is a barrier for someone of this presentation engaging in this type of therapy at all.

Continuing with the example of PTSD/trauma, we can also discuss the other two responses (fight and freeze) the brain may instruct when triggered, which are not just limited to a trauma survivor, but can be present in a number of different presentations such as autism spectrum disorders (ASD), generalised anxiety, etc.; in fact, any of us, at any moment could experience this during therapeutic processing. In Ref. [3] I describe in more detail the cognitive processes involved, and the nuances of cognitive/top-down therapies versus body/‘bottom-up’ therapies. When we experience a highly stressful or traumatic event, functioning in several areas of the brain is disrupted. Additionally, part of our brain called Broca’s area, responsible for retrieving verbal memory will shut down. Its function is to enhance our survival in a potentially unbearable physical or psychological painful event(s). What this means in relation to talking therapy, is that when we try to recall traumatic memories, Broca’s area will shut down in the present moment, leading to the client freezing in the room, unable to speak or move. This can disarm an unexperienced therapist, and re-traumatise the client, leaving both parties in a fairly powerless and hopeless position.

In considering the fight response and the relevance to working with clients in a room-based setting, similar can be said to the previous discussions. When attempting to process past memories, or indeed present experiences, particularly when clients are in a state of hyper-vigilance, there is just as much chance that their brain may respond with a ‘fight’ response. When shut in a room, this can be dangerous and traumatising for both the client and therapist, not least of all that the room can be a trigger in itself. If the therapist has experienced trauma themselves, and becomes triggered from a severe anger response, it could be an extremely dangerous situation if neither can escape. Whilst general safety measures are taught during therapy training for managing high risk situations, such as to sit in the chair nearest the door, and have a panic alarm nearby, if the freeze response occurs for the therapist in a highly charged situation, these safeguarding parameters become void.

The limited examples I have provided in this section are enough of an argument to consider the need for alternative settings or modalities, and not least of all in relation to the importance of the type of processing that is required for individuals in many presentation groups. As briefly mentioned above, there are times and situations where an individual is unable to attend sessions in a room, and more specifically, where there is a need for the type of processing to be non-verbal, or ‘bottom-up’ as opposed to ‘top-down’.

Top-down processing can be understood as cognitive-based talking therapy interventions, which rely on functions of memory and attention bias. When considering the information presented above in regards to Broca’s area, this form of processing poses a problem and indicates a need for an alternative intervention [3]. Furthermore, in considering other presentations or individuals who might struggle to engage in a talking therapy setting; executive functioning and attention bias are evidenced as key areas that are fundamental for cognitive or talking therapies to work. Consequently, for those with PTSD, ASD or similar presentations, an alternative, effective solution is needed.

2.4 The medical versus biopsychosocial model

When considering our human existence and our own sense of self, we are forced to consider our own world views on whether we feel our minds are separate to our bodies, or whether they are indeed interconnected as one. Cartesian theory suggests that our mind functioning is separate to our body functioning, and importantly to note, fits hand in hand with the medical model, adopted by national health services, medical insurance companies, the pharmaceutical industry, and medical practitioners today. The medical model attempts to locate within the body, individual ailments or disease; also known as pathologising. This way of understanding our human existence leaves little room to consider the environments we exist in, such as family, work, school etc., and the influences these play on our well-being; socioeconomic factors influencing diet, or workplace factors influencing stress for example.

In considering the topic of stress; it is a well-documented concept that stress caused from external environments has a strong relationship with physical ailments and disease. Let us consider I have a headache: I can either take a pain killer (medical model approach) or I can evaluate whether there’s something in my environment that is causing this, or perhaps how much water I have had to drink, or how much fresh air or exercise I’ve had. The latter way of considering the headache would be fitting with the biopsychosocial model, which differs to the medical model by taking into consideration the connection between body and mind, and takes the view that our bodily systems are all interrelated, and in relation(ship) with our external environments.

It can therefore be argued that talking/cognitive/top-down therapies are mostly based on the medical model approach, with exceptions such as sensorimotor and body psychotherapies, which may be conducted in a room-based setting alongside talking therapy. This poses several ethical questions about accessibility, suitability, inclusivity, working with diversity, and highlights the need for alternative interventions or approaches to traditional frameworks. Furthermore, therapists working within a room-based setting may feel limited to those confines, and, restricted therefore in their interventions in regards to responding to current global issues. Interventions carried out in a room-based setting, may encourage use of techniques, such as issues of anxiety raised about the client’s external situation, as being a platform for exploration of past events (e.g., CBT/Psychodynamic), placing the issue inside the individual, thus taking an individualistic, pathologising position, which could potentially be harmful to the client.

2.5 The importance of mind-body connection and bottom-up processing

As humans, we have evolved to move away from using our bodies as sensing tools in regards to primal safety, non-verbal communication, illness, and so on. Over time, we have formed a reliance on language as our primal form of communication; a reliance on cognitive processes to make sense of situations, including physical illness; and become increasingly dissociated and desensitised from our bodies. It is of my opinion that the over-reliance on these cognitive functions forms an extensive part of mental distress/disorders seen today. Take depression for example: clinical depression diagnosis is generally treated with medication and cognitive behavioural talking therapy, and commonly understood by society as being negative, or someone having something wrong with them (pathologising) by experiencing low mood or suicidal thoughts or feelings, thus fitting into the medical model appraisal.

The umbrella term of depression however, can be thought of very differently, as a straightforward, animalistic behaviour that is shared across the mammalian life span. In understanding it in this way, we can consider its purpose as being there to communicate when we need to hibernate, withdraw from our environment, rest, or process a difficult, stressful, or upsetting situation. This perspective would fall into the biopsychosocial model of understanding.

These examples start to paint a picture of how society has been conditioned to desensitise, and dissociate from primal, body-mind functions, and instead, adopted a shaming culture in which pathologising labels are used to diagnose one another. Following that, it is then expected that if you are not functioning in a typical 9–5 job; coping with the kids; your elderly parents; your kid’s school projects, and whatever else life throws at you, that there is something wrong with you.

For all the reasons named above, it is glaringly obvious that through human evolution, we have lost touch with our body-mind connection, and in doing so, the essence of our true selves and external environments.

2.6 Human evolution: adjoining the inner and outer worlds

According to Psych Central, ‘human beings have been talking about their inner lives and challenges with one another therapeutically for centuries’ [4]. Our inner world can be understood as our thoughts, feelings, emotions, beliefs etc., whilst our outer world are external factors making up and relating to our physical existence, such as material objects. It can be slightly more complex than this, as the outer world is also what we display and communicate to others. It has been said that our outer worlds reflect our inner worlds, but this opens up a curious topic for discussion. Does what we feel inside always match what we display to others in our outer world, and does it always align with the situation or setting we are in? For example: Susan’s sister is about to have life threatening surgery after a car accident. She is concerned and distressed, but has a presentation to deliver at work in order to secure an important contract; she is likely to display a professional, jolly, composed, disposition to her work colleagues on the outside, which does not reflect her true, inner world at that time. This process is likely a form of dissociation, which is where the brain has the ability to detach from our feelings and bodily sensations, including distress and physical pain. It is an inherent, primal mechanism which serves to protect us during highly stressful or traumatic events in order to survive.

Today, within our high-pressured culture, there are many situations similar to Susan’s where society dictates a set of norms or behaviours that are acceptable to display in public or as part of our outer world. One particular example comes to mind when considering a shared human, inner world experience, which is the feeling and expression of anger. Anger is one of Darwin’s six basic emotions which he hypothesises are shared across the human and animal life span [5]. Anger is a core emotion that we all experience as humans. It is another primal, survival response that serves to protect us when we are in danger, and ties in with the notion of fight instead of flight or freeze. Within society, healthy expressions of anger are not acceptable in many settings or situations, and in this case, there would be a need to not display our true, outer world. We are taught very early on as children that expressing anger is not allowed, and that it is bad, as opposed to emotions such as happiness, surprise, etc. Bearing in mind anger also serves as a primal safety mechanism (fight/flight), what do we then learn to do when we are in situations where we feel angry? As children, most of us would’ve found some form of dissociative mechanism that allowed us to detach from feeling angry, in order to display an incongruent reflection of our inner world to our outer world, which begs the question as to what else we dissociate from, and how normal this has become as part of human evolution.

The importance of living congruently between our inner and outer worlds is not something that is spoken about much outside the psychotherapy industry, nor is it particularly acknowledged, which suggests that incongruence in our lived experience has become a societal norm. My clinical experience both directly with clients, and indirectly through supervising practitioner’s work with their clients, shows a salient theme in regards to the societal pressure of holding it all together, and “keeping up with the ‘Jones’”, displaying an incongruent or false outer self. Children in particular, are increasingly suicidal from the emotional overwhelm, and pressure to cope and maintain this perfect image, which ultimately results in switching off the bodily, emotional, felt-sense and over using cognitive processes to try and fake. This leads to dangerous levels of dissociation and is currently creating a crisis that is unmanageable for national health services. As traditional talking therapy frameworks are in crisis, I postulate whether an alternative framework such as SST or indeed nature therapy interventions would be beneficial in attempting to manage this.

2.7 The importance of a congruent, environmental framework for therapy

Speaking very generally and across a broad spectrum of presentations, in my clinical experience, a lot of clients seek therapy due to a form of distress becoming intolerable or unbearable, resulting in difficulty experiencing emotions and the overwhelm these can cause. This can be because of coping strategies developed as a child to survive in the family environment; stress or trauma due to a single or prolonged experience; illness and so on. What I have experienced as a theme shared amongst these clients, are that their inner world experience is not able to align with their outer world, lived-experience; not dissimilar to Roger’s theory that clients seek therapy in a state of incongruence, that there is a conflict that they are seeking help to resolve. In exploring some psychological symptoms that might conceptualise these difficulties further, let us consider an example: Mark is a successful, driven, businessman who plays golf on the weekend with his friends. He is the life and soul of the party, but at home, he is quiet and introverted, and has started drinking a bottle of vodka each night, which is impacting his family/home life. He has contacted the psychotherapy practice to seek help as he is afraid of losing his family due to his drinking. I have given this example as I believe that even without psychotherapeutic training, we can see that there are two lived experiences for Mark, which we might infer as relating to both a congruent inner world reflection (the home experience of drinking etc.) and an incongruent inner world reflection (appearing to function as successful, life and fun of the party). The distress the conflict is causing Mark is what has led him to seek therapy.

Our work with Mark might involve exploring his inner world, and finding out if there is an underlying reason or process that is leading to the conflict between his inner and outer worlds, causing the intolerable distress that leads to the coping strategy of drinking alcohol/numbing, and feeling depressed. Whilst we could go a number of ways and much deeper with Mark’s psychological formulation, this section is about exploring the inner and outer worlds of our lived experience, and what that might look like. Mark’s example is sadly not uncommon, and is a classic illustration of trying to function in a society that demands a certain level of functioning, including what emotions and feelings are acceptable to show to the outside world. As a result, Mark is left with a distressful, incongruent existence.

2.8 Nature therapy and its applications

Whilst the same could be said for traditional room-based settings in some areas; a core strength of nature therapy is the broad range of settings and activities that can be offered to different groups of people with varying abilities and disabilities; those who are non-verbal and or experience difficulty in speaking, including language differences; and ethnic and socio-economic factors. It has been highlighted in previous discussions in this chapter, that room-based settings pose ethical compromises for inclusivity and working with diversity; nature therapy is able to lend itself to working with a broad range of presentations including trauma/PTSD, ASD etc.

Nature offers a congruent, non-judgmental space for people to recover. These attributes are parallel components to the humanistic conditions that Rogers specifies as necessary for therapy to be effective. In nature, people feel they can be their true selves, and consequently can feel ‘at one’ or connected to nature, regaining the natural connection to their body, emotions and feelings. This is not only experienced as a relief, but often an opportunity to process and be with feelings that have been avoided or numbed for long periods of time. When combining nature with traditional frameworks of psychotherapy, there is something that is immediately shared in an experiential way between the therapist and client in comparison to a room-based setting. We have all experienced being in or around nature at some point in our lives, and according to existing literature, we will have had at least one positive experience in doing so. It could therefore be suggested that the nature element has a positive influence on the therapeutic relationship, which, as Roger’s first postulated; is the core of successful therapeutic encounters. In the same vein, our own relationship with nature encourages something phenomenologically different to emerge, in comparison to what might be experienced in a room-based setting, where, without nature, an incongruent self can still be present. Consequently, nature therapy alongside even an SST session is likely to be a positive substitute for traditional room-based frameworks when considering this aspect. When combining nature therapy with SST, accessibility in terms of affordability and time commitment, supporting an autonomous, client-led service, are offered.

Allowing a natural space to connect to the body within therapy sessions can lead to processing of feelings, emotions, and memories that are stored in the body. Van der Kolk’s extensive research suggests that body processing is required in order to work with trauma, in particular which can lay dormant in the body for years [6]. Additionally, other neuropsychological research has taught us, that rather than pushing away or ignoring and numbing thoughts and feelings, and instead taking time to feel and experience them, actually leads to positive processing and being able to move on and detach from unhealthy patterns [7]. In some cases, solely relying on talking therapy in a room-based setting, can mean that clients are unable to move away from repetitive, intrusive and overwhelming thoughts and feelings, and get stuck on a loop through rumination. We could be the best psychotherapy practitioner in the world, delivering the perfect intervention, however, it is clear that as mankind has evolved, in a lot of cases, we require something more than talent and traditional psychotherapeutic frameworks in order to address complex dissociative and embodied issues.

2.8.1 Benefits of nature therapy

The direct physical and mental health benefits experienced from nature have long been documented in scientific studies, as well as qualitative measures that report client’s verbal accounts of their experiences in nature. Since the global pandemic occurred in 2020, salience of people recognising the importance of connecting to nature for their mental as well as physical wellbeing by gravitating to natural spaces, has been well documented. Bringing nature indoors, spending more time in the garden, and travelling to green or outdoor spaces have become increasingly popular as people experience the benefits of nature to their physical and mental wellbeing.

Nature therapy is diverse in its applications, as not only can practitioners work with clients outside in a broad range of settings, such as the beach, forest, countryside, and garden; it is also possible to experience the benefits of nature inside the room. The latter lends itself to ensuring inclusivity and all corners of the population are able to be reached, no matter what their psychographic or demographic. Including nature within the room-based setting can be achieved by bringing natural elements such as sand, plants, and water into the surroundings to create a natural environment inside. These elements can also be used through other senses such as touch (sand or plants), smell (plants with perfume/strong scents), or sound (running water, rain, birds and wildlife sounds). Working in this way offers a platform for mind-body connection, grounding and working in an embodied way, which research literature suggests is necessary, particularly in considering the prevalence of dissociation and internal conflict which can be argued, is causing a lot of mental illness and dis-ease. Once again, nature therapy can lend itself to working well alongside other therapeutic modalities, which offers a broad and diverse way of working with many presentations. Importantly, this means that the issues discussed previously surrounding disconnection to the body, and reliance on cognitive processes as an intervention, can be re-evaluated and combined with a somatic, nature approach.

Working in nature also addresses societal challenges relating to stigma in accessing psychological services. Attending a session in a green space is far more appealing to those with pre-conceived concepts of the negative connotations surrounding psychotherapy, and consequently makes nature therapy accessible to large demographics of people who may not ordinarily seek help. On an organisational level, this can boost engagement rates for services, and improve service level outcomes. The physical and psychological benefits of spending time in nature have been reported for centuries. There is a large body of research that has documented the following benefits, specifically from engaging in nature assisted psychotherapy [8, 9]:

• Reduced anxiety, stress, and depression

• Increased self-esteem and positive self-image

• Reduced cortisol (stress hormone) levels, which in turn has been shown to reduce physical pain and emotional overwhelm, thus supporting PTSD and borderline personality disorders

• Improved mental as well as physical relaxation, thus supporting anxiety and ADHD presentations

• Increased feelings of ‘awe’ which is related to gratitude and selflessness: these emotions documented in improving mental states of mind

• Physiological relaxation, which leads to a restorative impact on the parasympathetic nervous system, supporting stress & trauma presentations, borderline personality disorders and more

• Overall, the psychological benefits have a direct impact on the positive function of the immune system, thus improving physical health. It is also documented that nature therapy lowers heart rate

2.8.2 Practical exercises for working with nature therapy

As discussed earlier, there are a multitude of variations for working therapeutically in nature. As this book is directly relating to psychotherapy and counselling, the following exercises are suggested for suitability for that context and framework. Whilst it is important to consider the evidence base for efficacy of any intervention we are delivering; less is known about traditional psychotherapy models being combined with outdoor/nature spaces. That said, there is a growing evidence base for combining the two, and also for enhancing traditional settings by bringing alternative or nature therapies into the room, as well as saliently, by incorporating mindfulness into the session (e.g. Mindfulness based cognitive therapy).

2.8.2.1 Walk and talk

In its most basic form a ‘walk and talk’ in any green space can be understood as transferring the therapist’s skills to the outside environment, and conducting the session as you would inside a room, but instead, walking instead of sitting. Additionally, grounding and mindfulness exercises can be included to ensure the client is having an embodied experience and remains grounded and safe. This exercise can work well for meeting and sitting somewhere outdoors in nature (preferably somewhere that protects the client’s confidentiality) and offer another option for those who may find walking physically challenging. This exercise creates opportunity for an embodied experience and allows authenticity and congruence, encouraging a body-mind connection.

2.8.2.2 Forest bathing

Forest bathing derives from the Japanese practice known as Shinrin-Yoku. It was developed as a practice for physical as well as mental wellbeing. The idea is to immerse yourself in the forest surroundings by using all five senses. Similar to the walk and talk, this exercise offers opportunity for an embodied, mindful experience, encouraging body-mind connection and an authentic encounter. Sessions can include guided meditations and moments of stillness, either sitting or standing.

2.8.2.3 Mindfulness

Most agree that the definition of mindfulness is simply to pay attention to the present moment by using all five senses. In doing so, we can introspectively reconnect to our body and mind moment by moment. This offers clarity, improved cognitive function, and a reconnection between body and mind. It can consequently help to realign a congruent experience between a person’s inner and outer world. Simple mindfulness exercises can be to notice the surroundings, and what you can see, hear, touch, smell, or feel. In nature, we can ask the client to notice every step they take, and how it feels when their foot is connected to the earth etc. Being mindful helps to improve mood, and lower anxiety, as well as increase emotion regulation. Mindfulness based cognitive therapy (MBCT) is a powerful tool, and fitting with the concept of combining nature interventions with room-based work. MBCT teaches the client to pay attention to their thoughts, which in turn can positively impact and change unwanted feelings and behaviours.

2.8.2.4 Grounding

Grounding exercises in nature can be as simple as hugging a tree for a few minutes, to walking barefoot (where safe to do so); or planting seeds/plants with bare hands. This direct connection to nature improves the body-mind connection, and this improves the physical and psychological state of a person. Another grounding exercise that is particularly useful when someone is having a panic attack, is to get them to turn their head and body 360 degrees, as slowly as they can, and notice everything that they can see. Some people like to say the things they notice out loud, others in the mind. If a person is highly anxious, and this interrupts a session continuously, grounding exercises can be done as often as needed.

2.8.2.5 Meditation-guided body scan

For a highly stressed, anxious, or dissociated person to have an embodied experience in nature, a powerful exercise to carry out is a body-scan meditation. It is a great exercise for moving a person away from over-reliance on cognitive function and processes, and into their body. To carry this out, the practitioner invites the client to close their eyes, or focus on something still in the distance. Relaxed, long breaths in and out are encouraged, directing the client to breath into the stomach space, as opposed to the chest. The practitioner then leads the client to mindfully notice each and every part of their body, from head, to arms, to stomach to toes. Throughout this process, it is common for people to struggle with intrusive thoughts, distraction etc. The practitioner must encourage the mindful practice of noticing these thoughts or feelings, and bring the focus back to the body or the breath each time it occurs. At the end of the scan, the practitioner can ask the client what it is like to be inside their body, whether it is the same or different to usual, etc. They then guide the client to bring awareness back into their surroundings by noticing any sounds or sensations they can feel or hear, and to gradually open their eyes. The practitioner can then explore with the client if they noticed anything during the body scan. This exercise can be carried out at the beginning, and repeated by the practitioner or the client as many times as is needed throughout the session if beneficial. Please note that this exercise may not be suitable for highly traumatised individuals, early on in their process, before they have reached a period of stabilisation. This is due to the levels of dissociation being so high, and at this stage of a client’s process, leading them into their bodies can be extremely re-traumatising.

2.8.2.6 Mandala creation

The term ‘mandala’ derives from Sanskrit and translates as ‘circle’. It is a creation of geometric patterns, often used to depict elements of the universe, incorporated with Buddhist and Hindu teachings. In the nature therapy context, mandalas can be created as a form of art using natural elements. The client can be directed to collect flowers, leaves, and different natural elements using a variety of textures and colours. To start with, they would create one large circle on the ground with leaves for example, followed by smaller layers inside. This can be delivered as both a mindful and grounding exercise, and the mandala can be used to represent a dream, the client’s life, self-image, as an ending exercise to represent their journey of therapy, etc.

2.8.2.7 Bringing nature therapy inside the therapy room

If you would like to create a natural environment inside the therapy room, you can bring in plants, flowers, rocks, sand, water, fish etc. You can ask the client to connect to the nature through meditation, or breathing it in, or indeed to touch or feel the natural elements. Listening to nature sounds can also promote relaxation, and this can be used as a grounding or mindful exercise. Another exercise that doubles as both mindful and grounding, is planting seeds/flowers. This can also be a metaphor for the client’s new journey into therapy. Using sand to create art, or simply to feel and notice the texture can be a useful tool to encourage an embodied experience. Asking the client to hold a rock or form of nature, can work in combining a cognitive therapy intervention with nature therapy. Feeding the fish in the tank can open up dialogue for the meanings of care-taking, encourage connection with nature, and thus with self. Exercises observing the fish can also be very beneficial. A mandala can be created on paper using sand, and other natural elements that the therapist can collect prior to the session.

2.9 Ethical considerations for nature therapy

There are a multitude of questions that the basic ethical framework poses, and many referral agents will ask, when considering working with clients in outdoor spaces. It is crucial to create policies and procedures in order to address these. Below are 10 examples of questions and areas to be thinking about if you would like to work with clients in nature:

1. Will the professional liability insurer cover the work being carried out in an outdoor setting?

2. What will the procedure be for meeting the client on arrival or the time of their session in place of a receptionist and waiting room, and as such how will the boundaries for start and finish times be managed, including clients arriving/leaving at the same time, and a possible comfort break in between sessions for the therapist?

3. Is the client’s confidentiality protected when conducting a session in a green space, and if there are compromises, how will the client be fully informed and consent to this?

4. Are there any safety issues pertaining to working outdoors for mental health or physical risk, e.g. do you need to carry out a screening and inform the client of any physical risks, and in doing so ensure there is an appropriate risk assessment in place for the service (refer to Section 2.6 for more information)?

5. Does the client need to be briefed on any suitable clothing attire to wear, e.g. sturdy shoes for walking, a sun or rain hat?

6. Is the therapist first aid trained in case of an emergency/will they carry a first aid kit, and what will the first aid procedure be?

7. What type of lone working safety parameters are in place if this is the case?

8. Will you need extra training in this area to ensure ethical competency of work is upheld? For example, a ‘continuing professional development’ training on ecotherapy.

9. Will you outline potential risks or confidentiality compromises in a therapeutic contract to ensure the client is fully informed and consenting to the work being outside.

10. Will you conduct all your sessions in the outdoor setting, or some in a room-based environment? For example, would it be a sensible safety measure to conduct a telephone or in-person room based initial assessment/screening to ensure the setting is safe and suitable for the client?

2.9.1 Addressing diversity and inclusion in nature therapy

It could be argued that there is a slight ethical dilemma in defining who can/cannot participate in nature therapy when you are using a client-led model or approach, as ultimately, we aim to offer the client full autonomy over their decisions regarding how they participate in therapeutic activities. That said, psychotherapeutic frameworks must be based on safety and managing risk, and the importance of creating a boundaried framework for the service, are what fundamentally help to maintain client safety and manage risk, in order to provide a safe space for effective therapy to take place.

The University of Exeter in the UK have created a handbook [10] for services to refer to when working with service users in a range of therapeutic nature settings. They suggest that the following be taken into consideration when going through the referral and or screening stage:

Ref. [10] suggests that the most important element to building trust with service users or referral agents for nature therapy are: honest and accurate information sharing of the site description. It could therefore be suggested that this falls in line with a client-led model due to the transparency and level of openness in information sharing, which fully informs the client/care giver, and allows them to make an autonomous decision on whether they feel the nature therapy is suitable or safe for them. That said, it should also be taken into consideration the vulnerability of each individual client and their capacity to make decisions safely, as well as a person’s lack of experience engaging in a nature therapy session, and the therapist’s knowledge of this.

Aside to the general areas mentioned in Table 1, during the referral process it could be argued that other considerations should be made for socio-economic and ethnicity factors, that may affect a person’s desire or reluctancy to engage in nature therapy. Ref. [11] found that the way in which nature is generally used by different ethnic groups can differ significantly, and may therefore impact their overall experience of nature therapy, and consequently its effectiveness. Evidence suggests that there is a correlation between a person’s desire for nature and the effectiveness of nature therapy and vice versa. The research found that in some cultures, the association between past generational trauma and hardship can influence cultural and ethnic attitudes towards nature [10, 11]. It may therefore be a criterion to take into consideration at the initial screening, and consideration be taken for whether this type of therapy would be suitable or indeed damaging to the client, or whether this challenge could be positively overcome.

Age

Weather

Site Description/Type/Terrain

Length/Number of Sessions

Detailed description of what will take place

Clothing & Equipment

Transport Availability

Limited Mobility/Disabilities

Table 1.

Referral screening considerations: information taken from ‘Nature on Prescription Handbook’ [10].

Accessibility to services is a key area for consideration in this topic. When reflecting on socio-economic factors, it is well understood that psychotherapy has long been framed as being for the private sector, or those who can afford the luxury. This may present as a barrier for engaging in psychotherapy in any setting, and efforts should be made to ensure that the service framework is inclusive and suitable for people from all economic backgrounds, and to think about things like affordability and accessibility if someone does not have transport. Many green spaces are not on main bus routes, and consequently when thinking about the location for the service, this factor should be considered, in order to not exclude certain people who may not own their own transport. It may be that you are able to offer a shuttle or taxi service as part of your service.

2.9.2 Psychological risk factors

Further consideration in the area of screening and procedures for referral in nature settings is imperative, just as with managing the safety and suitability of services, settings and practitioners, in relation to ethical frameworks such as British Association for Counselling and Psychotherapy [12] for room-based settings. Risks for working outside or in nature must be identified as part of this umbrella framework. The below Table 2 lists some examples of the areas for consideration and identifies some presentations and behaviours that require risk assessments. Although risk assessments do require careful thinking and extra, detailed paperwork, in most cases, they can allow a diverse range of service users access to therapies that they may have been excluded from otherwise, thus supporting an inclusive, client-led framework.

Presentation/behaviour	Brief description of identified risks for consideration	How might this be managed
Schizophrenia	Interruption of cognitive function due to auditory/visual hallucinations which can lead to harm of self/others/risk of fleeing in outdoor space	Working in smaller spaces such as a fenced garden, ensuring a care or support worker/close relative nearby/present. Ensuring prescriptive medication is being taken as a condition for attendance
Dissociative Identity Disorder	As above, plus risk of anxiety/panic attacks	As above. Agreeing with the client the importance of transparency when experiencing symptoms and identifying red flags for relapse. Not attending sessions when relapsing if risk too great (risk assessment at screening stage to determine this); provisioning support person to attend and share responsibility for safety; contract with the client beforehand that they must disclose at any point during or outside of the session when they are experiencing symptoms ensuring provision for safety measures/alternative plans.
Post-Traumatic Stress Disorder	High evidence for correlation with substance/alcohol dependence, self-harm, anxiety attacks; triggers in open environment and flashbacks could lead to severe distress, self- harm & suicidality	As above, and including in the contract that sessions are dependent on attending when not under the influence of alcohol or drugs.
Self-Harm/Suicidality	A larger environment, more options for potential ways to harm	Contracting for transparency and full disclosure for self-harming before, during and in between sessions, encouraging client to disclose when the urge occurs during a session in order to safeguard as best as possible. It may be useful to get the client to keep a weekly diary to monitor patterns and identify times of higher risk. Plus, in-depth risk assessment of potential dangers at the site and for the client at screening stage. Possible support workers, considering not lone working; working in smaller, secure area as opposed to remote, open area.
Substance or alcohol dependence	Being under the influence may impair judgement for making rational decisions- risk of harm to self/others	Ensure to agree in the therapeutic contract the safety implications around not being able to work together if the client should arrive at their session under the influence. To encourage transparency of the client to disclose this. To consider alternatives in order to ensure oppression and inclusivity are considered and supportive of a client-led model, by offering an alternative option; for example, an online session/phone call that is recorded.
Referrals from high security forensic services	Potential for cluster B personality disorders and harm to others, particularly where violence has been used in the past. Secluded environment away from human resources.	Depending on each individual, the setting, and whether it is group/individual work, it would be suggested to have plenty of human resources nearby, and support workers who have an existing relationship with the clients and who are trained in physical restraint in case of physical violence. In these cases, confidentiality within the ethical framework should be carefully considered in order to best support each client. It may also be suggested that consideration for the type of nature therapy (e.g., creation/active horticulture in place of mindfulness in a forest) and working in an enclosed setting which is not too remote.

Table 2.

Presentations relating to metal health diagnoses that require risk assessment.

Table 2 illustrates some examples of areas that require careful thinking, planning, and risk assessment, and the list is endless; however, for the purposes of this chapter, limited examples have been provided. Aside to risk assessments and general considerations for direct harm to service users; it is also important to include the practitioner/therapist and any support workers within these processes. Importantly, a lone working policy must be in place, and where necessary, extra support and human resources present/available. Considerations for health and safety for all stakeholders must also be in place, just as with other settings. It goes without saying that in any setting, when working with high-risk clients, regular supervision and self-care are of central importance in any case.

3. Conclusion

Traditional therapeutic frameworks are well documented as being effective and necessary in many contexts and settings. There is however, a growing need to address the incongruent way of being that society has created, along with the disconnect between body and mind. Additionally, as a result of this, the coping strategies and damaging behaviours that have been adopted to manage this unnatural way of surviving, is causing a crisis, and necessitates more than what the traditional frameworks and settings may be able to offer. Aside to this, as discussed, certain presentations are not suitable for traditional settings, and an alternative framework is needed.

Nature provides a platform for an embodied, grounding experience, which acts as a powerful, multi-dimensional process in comparison to room based talking settings. Furthermore, as has been documented throughout this chapter, evidence suggests that alternative, bottom-up processes are needed in order to address a broader range of presentations. A single session in nature in comparison to several sessions in a room-based setting do not seem to be of equal comparison. Offering SST in nature creates a platform for combining evidence-based strategies, that support a diverse, inclusive, and ethical framework for psychotherapy. This combined approach allows flexibility to address the evolution of society by offering a timely and financially affordable solution.

Conflict of interest

It could be considered a conflict of interest that the author works within a nature therapy setting, and consequently there may be some bias expressed in the writing.