A natural fit

As a practicing psychologist with training in sport psychology, Michelle Joshua, PhD, knew she was in the right field to pursue her passion: helping people face challenges and grow from them. 

Less appealing about the field was working in an office all day.

"I'm an athletic person and I wanted to work primarily with athletes and people who could benefit from being more active," says Joshua, who earned her PhD in counseling psychology from the University of North Texas in 2002.

So, Joshua founded Work it Out LLC, a clinic with offices in Raleigh and Carrboro, N.C., that helps athletes address performance and personal issues, and provides health and behavior interventions to people with conditions including diabetes and obesity. Part of that work involves walking on trails near her offices.

"I thought that incorporating exercise into my clinical or performance work might allow clients to address issues in a way that felt more comfortable for them than talking face to face, or would give them the opportunity to literally get off the couch as opposed to talking about it," she says.

Joshua is one of a growing number of clinicians who have figured out how to bring exercise and the outdoors into their practices in a way that's both ethical and effective for clients. Research is scarce on how many psychologists fit that bill, but a 2010 sample of 204 psychology practitioners interested in exercise and psychotherapy found that 86 percent exercised regularly, most recommended exercise to clients, and 18 percent exercised with clients during therapy, according to consulting psychologist Kate Hays, PhD, of The Performing Edge in Toronto.

Besides exercise's proven ability to combat depression, anxiety, insomnia, weight gain and other health and mental health conditions, combining it with therapy has benefits of its own.

For one, it can model good exercise behavior for clients, Hays says. It can also provide a bridge to help people actualize their exercise resolutions and ease rapport with certain types of clients, she and others say.

"There are some people who become blocked or overwhelmed by the intimacy of therapy in an office setting," says Jennifer Lager, PsyD, who walks with clients on trails along the Potomac River as part of her practice in McLean, Va. Trauma survivors, for instance, often carry a lot of shame and may have created rigid walls to protect themselves. Directly facing the therapist with no outlets for their physical arousal may prove too intense for them at times. Meanwhile, adolescents and people with attention-deficit disorders may have trouble sitting still.

"There's something about getting them out and moving that helps them relax," she says.

Being outside can also build rapport and humanize the therapist, Lager adds. She recalls one teenage client who was scared of bees. As they walked, "a bee came by and kind of flew in our faces," she says. "We both reacted with a little bit of shock, and it was funny. I think those shared moments help very much with the interpersonal connection that's shown to be such a crucial element in what makes therapy work."

Research also is starting to show that creativity, self-awareness, emotional awareness and other positive therapy outcomes can heighten during movement. That may have to do with greater blood flow to the brain, the activation or deactivation of specific brain centers, "and probably with some kind of distraction element that allows the mind to become clearer," Hays surmises. Psychologist Arne Dietrich, PhD, of the American University in Beirut, for instance, proposes a "transient hypofrontality" model suggesting that when we exercise, the brain focuses on what it needs to do for those activities. In the process, it decreases activity in the left hemisphere and opens the way for creative insights in the right.

For many people, nature can be grounding as well, says Katie Asmus, a licensed psychotherapist and wilderness guide in Boulder, Colo.

"There is something about the environment that helps our nervous systems unwind," says Asmus, whose office overlooks the Flatirons, large rock formations bordering Boulder that are a haven for rock climbers. People who walk or run in natural environments report less anger and sadness directly after exercise than those who walk or run in "built" environments, finds a 2010 meta-analysis in BMC Public Health by Diana E. Bowler, PhD, of Bangor University in North Wales, and colleagues. In another series of studies reported in the June 2010 Journal of Environmental Psychology, participants said that being in nature made them feel more alive, beyond the effects of physical activity and social interaction in the outdoors, according to University of Rochester psychologist Richard Ryan, PhD, and colleagues. And studies beginning in the 1990s by psychologists Terry A. Hartig, PhD, Roger S. Ulrich, PhD, and others show that nature helps to quell anxiety and even heal the body.

"When we're more open and more relaxed, it helps us access deeper parts of ourselves and our emotions — layers of ourselves that we often don't have the opportunity to experience otherwise," Asmus says.

How to do it

It isn't difficult to include walking and the outdoors in your practice, but some tips can help you head off potential problems. Experts advise you to:

• Keep it confidential. Going outdoors means you may run into people who know you or your client. Address this possibility up front and figure out a strategy beforehand, Lager advises. She and her clients agree that if they see someone they know, they'll indicate that to one another and simply stop talking until the person is out of earshot, for example. Similarly, Hays recommends role-playing possible scenarios, or just saying hi and moving on. "My own experience is it's never been an issue," she says.  
• Maintain boundaries. When the body is involved in therapy as well as the mind, "questions about power and sexuality implicitly arise," says Hays. Male therapists and clients may feel pressed to compete with one another, for instance, while female clients may negatively compare their athletic abilities or appearance with that of the therapist.
  
  Defuse possible discomfort by strongly establishing the framework as psychotherapy first and foremost, essentially by making it explicit, recommends Hays. She writes about this issue in the third edition of "Exploring Sport and Exercise Psychology," edited by Judy L. Van Raalte, PhD, and Britton W. Brewer, PhD, due out this year. "Discuss with your client the idea that you are still doing psychotherapy; you're just changing the medium in which it occurs," she suggests.
• Share the good news. Keep current about the benefits of exercise and the outdoors and share that information with clients, says Lager. "It helps to be well-versed about the benefits of exposure to natural light, the mood benefits of moderate exercise and the fact that we're not built to be sedentary," she says. A growing body of research shows that even a regular exercise schedule may not be enough to counteract the effects of too much "couch potato" behavior, for instance — so the more movement, the better.
  
  In surveys she's conducted with her walking groups, Lager has found that her clients' moods improve after the walks. What's more, she found that group walks sparked some clients — most of whom hadn't exercised much before — to walk on other days by themselves.
• Get creative. When Asmus walks with clients on the trails near her office, she finds ways to use the natural world metaphorically, symbolically and therapeutically. For instance, she may instruct clients to wander off alone for a few minutes and find an object that represents an issue they're working on — a rock that symbolizes the need for more groundedness, for instance, or a feather signifying the need to let go of a harmful habit or person. Object in hand, the two then discuss ways it can serve as a metaphor to provide insight or guide their work in that area.
  
  In a related vein, the natural world produces amazing instances of synchronicity, Asmus says. On one walk, a client was talking about a dream that included three horses. The next minute, three horses and their riders appeared around a bend in the trail.
  
  "Things like that happen so often in the natural world," Asmus says. "Animals show up and can mirror what is happening with people, either directly or more metaphorically. It helps people open up their perspectives and see their issues in a different way."
• Respect the client's preferences. Don't push walking or exercise on a client, and be flexible about how the session goes, Joshua says. "Some people like to motor it, and others just shuffle," she says. "If they come in and say, ‘I'm tired,' then we're not walking. It's totally up to them."
• Keep it simple. Asmus suggests starting with small things, like bringing natural objects into the therapy room, or walking into the backyard or park for a few minutes. If therapists seek deeper or greater skills, there are plenty of training options available (see Outdoor wilderness resources).
  
  "You don't have to be a backpacking instructor to incorporate the natural world into therapy," she says.  
• Monitor the conversation. Be aware that exercising outside with your client may alter the type of communication you have. That can be good when it sparks creativity, both in the client and the therapist, says Hays. "There is potential for much more openness and disclosure, capacity for insight, the ‘aha' moments that we know are facilitated by physical activity," she says.
  
  For other clients, though, going outside may promote avoidance, cautions Lager.
  
  "While walking may be distracting in a good way for someone who gets hyperaroused, it could keep others from going as deep as they might," she says. In that case, make sure to address it with your client.
  
  "There may be clients for whom the office environment is a better fit, and others who do well with a combination of the two," she adds. "As with any therapy, one size does not fit all."
• Monitor yourself, too. In a related vein, check with yourself about whether you think you're accomplishing treatment goals in this format, says APA's Assistant Executive Director for Practice Research and Policy Lynn Bufka, PhD.
  
  "Integrating psychotherapy with exercise is likely a new approach for many clinicians, so it's important to be honest with yourself about treatment progress," she says. Check in periodically with your client to assess how things are going, she advises.

Growth potential

Psychologists who combine exercise and therapy are believers in its benefits. However, Hays says more research is needed on how the two operate synergistically. Other areas ripe for study include examining which aspects of therapy are best facilitated by exercise — insight or catharsis, for example; whether certain types of people benefit more from exercise-talk therapy than others; and what kinds of exercise other than walking might be useful adjuncts to therapy. In her 2010 survey, for instance, Hays found that 80 percent of therapists who exercised with clients did so via walking, but 10 percent also ran with clients and 40 percent played noncompetitive sports, such as shooting baskets or throwing a softball. 

Scant data notwithstanding, it's apparent that combining exercise and therapy accomplishes at least one important goal: helping people do two healthy things they might otherwise put off.

"With exercise, you often hear excuses like, ‘I don't have enough time.'" says Joshua. "A lot of times, people don't want to take the time to do therapy either. When you combine the two, it makes it easier to do both."

Tori DeAngelis is a writer in Syracuse, N.Y.