A presentation by Sam Cooley at the 2022 annual conference for the British Psychological Society, Division of Clinical Psychology (DCP). Abstract: Objective: Existing evidence suggests talking therapy can be highly effective when located outdoors. However, much of the previous research is centred around counselling and psychotherapy professions. The aim of the present study was to explore the attitudes and experiences of clinical psychologists. Design: A cross-sectional survey was used to gain a broad perspective within the profession. Method: A total of 215 participants completed the survey between August and October 2021. Efforts were made to ensure a broad and representative sample located across the UK and comprising mixed interests and experiences. The survey contained detailed demographic questions and previously developed scales to measure nature connection, experiences and attitudes towards outdoor practice, as well as variables underpinning the theory of planned behaviour. Analysis included descriptive, correlational and regression analysis. Results: The findings outlined a marked increase in outdoor practice since before the Covid-19 pandemic, with 32% of participants reporting either occasionally or regularly offering therapy outdoors (“never” = 36%; “rarely” = 32%). The majority held outdoor appointments in public parks (64%) and engaged in sitting (81%) or light walking (86.1%). Findings identified common reasons for offering therapy outdoors and barriers to this way of working. Significant, positive predictors of outdoor practice included years qualified, professional confidence, nature connectedness, outdoor leisure time, instrumental attitudes, perceived norms and self-efficacy. Conclusions: The findings reveal favourable attitudes and a growing community of clinical psychologists who practice outdoors. The presentation also highlights approaches needed to further address barriers still faced by many practitioners, to support safe and effective outdoor practice.

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Outdoor therapy:
Maverick or mainstream?
A survey of clinical
psychologists
Dr Sam J Cooley PhD DClinPsy
Clinical Psychologist @SamJoeCooley
Co-authors: Eleanor M Taylor; Kristina
Ceslikauskaite; & Noelle Robertson
University of Leicester

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Overview
• Introduction to existing research on outdoor therapy
• Introduction to present study
• Methods
• Results
• Conclusions
• Future research

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Existing research
Previous systematic reviews:
• e.g., Annerstedt & Währborg (2011)
• Bowen & Neill (2013)
• Bratman et al. (2012)
• Cipriani et al. (2017)
• Coon et al. (2011)
• Twohig-Bennett & Jones (2018)
• White et al. (2019)
Psychological, physiological & social benefits.
≥120
minutes
per week
(White et al.,
2019)

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Health care environments
‘Healing environments’,
‘Evidence-based design’
’Biophilic design’
(Sadek & Willis, 2020)
‘Sick building syndrome’
(WHO, 1983)

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the Physical environment in therapy
“a person and their
environment shape each
other and constitute a
whole ... environmental
features may affect
clinical practice.”
(Morrey et al., 2020)

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Review aim
• To explore the experiences of practitioners
and clients who have practiced talking therapy
in outdoor spaces.

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Enrichment
• access and equity of care for clients;
• shared ownership of the therapy space and relationship;
• freedom of expression & escape from day-to-day routines;
• physical movement and/or dynamic surroundings
supporting psychological flexibility in those who feel
psychologically ‘stuck’;
• restorative effects of time spent in natural settings;
• interconnectedness with the natural world;
• holistic benefits to the clients’ and practitioners’ physical as
well as psychological health.

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Article characteristics
• 38 articles (1994-2019)
• 322 practitioners (58% female, 36% male)
• Psychotherapists = 37%
• Counsellors = 32%
• Counselling psychologists = 18%
• Clinical psychologists = 16%
• 53% used an integrative modality
• 37% USA & 21% UK
• 45% private practice, 29% educational/academic settings

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• Qualitative study
• 15 senior figures in
Clinical Psychology
• Organisational
perspectives on
outdoor therapy

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Force of tradition
“You are constantly working with the assumption that what we
do is safe and good. And, therefore, everything that you’re
trying to change people to, you’ve got to prove overwhelmingly
that it’s somehow significantly amazing. Whereas we could be
sitting delivering something that is inherently bad, and people
wouldn’t see that, because they’re already doing it ... The most
common reason that people do what they do is because it’s the
way they’ve always done it. So, it’s such a powerful bias in how
people approach their work ... people work to their default way
of working.”
(Participant 2)

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Internalised risk
“I think we are quite risk averse, often in a way that’s not actually
helpful to clients ... the idea that you can do psychotherapy without
risk is complete nonsense because if it’s done right, it has the power to
transform someone’s life and change it for the better. But any
intervention with that degree of power, if you make mistakes it can
cause harm. But then you can’t do anything that doesn’t have that risk
... The crucial thing is that people need to take informed consent if
they’re capable of consent and they know the risks ... But a lot of
[practitioners] internalise the barriers and they imagine that, ‘oh no,
they wouldn’t like that, I better not do that’... They become their own
policeman and have this internal finger wagging ‘oh you mustn’t, no,
no, it could go horribly wrong, what if something happened’”
(Participant 11)

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https://cms.bps.org.uk/sites/default/files/2022-
06/Use%20of%20talking%20therapy%20outd
oors.pdf
BPS guidance document
(Cooley & Robertson, 2020)

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In summary
• The therapy environment is important
• Outdoor environments are used less in clinical
psychology
• Things may have changed during the pandemic
• More research is needed into what CPs are
currently doing

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Aims of present study
• To explore attitudes towards and
experiences of outdoor therapy in clinical
psychologists
• To understand what influences attitudes
and behaviour towards outdoor therapy

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Methods – The online survey (10-15minutes)
 General demographics
 Health/physical activity (Marshal et al., 2005)
 Confidence in talking therapy
 Nature connectedness (6 Nature Connectedness Index; Richardson et al., 2019)
 Experience of working outdoors (2-item; Wolsko & Hoyt, 2012)
 Types of outdoor practice
 Barriers to outdoor working
 Theory of planned behaviour items measuring attitudes, perceived norms,
perceived behavioural control, intention (Francis et al., 2004)

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Participants (N = 215)
• Age 24-61 years (M = 34.95; SD = 8.90)
• Female (n = 177; 82.3%), male (n = 36; 16.7%) and non-binary (n = 2; 0.9%)
• 18 different countries; majority born in the UK and Ireland (n = 195; 90.7%)
• Majority White British (75.8%)
• Trainee clinical psychologists (57.2%), qualified clinical psychologists (33.5%),
consultant clinical psychologists (9.3%)
• Years since qualification 0-35 years (M = 10.82; SD = 9.14)
• 93% worked in the NHS

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Participants (N = 215)

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Results - Descriptives
Urban,
22.3%
Suburban,
45.1%
Rural,
32.6%
Where did you grow up?
Urban,
39.5%
Suburban,
42.3%
Rural,
18.1%
Where do you currently live?
Urban,
59.5%
Suburban,
31.2%
Rural,
9.3%
Where do you work?

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Average weekly exercise
(> 4 = ‘sufficiently active’)
Do you have any physical health conditions that would impact your
ability to engage in low intensity outdoor activities (e.g., sitting and
walking)?
Mean = 4.27;
SD = 2.24
Yes = 7.9%
No = 92.1%
Physical Health

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19.5%
32.1%
34.4%
11.6%
2.3%
Never Rarely Sometimes Often Always
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
To what extent do you use therapy
interventions that involve nature?
36.3%
30.7%
27.4%
5.6%
0.0%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
Never Rarely Sometimes Often Always
To what extent have you met with
clients in outdoor locations?
Behaviour

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• Public parks & gardens = 64.2%
• Outdoor seating areas = 52.6%
• Private parks & gardens = 40.2%
• Streets & roadsides = 24.1%
• Cities and shopping areas = 19.7%
• Footpaths & trails = 19.7%
• Woods & forests = 9.5%
• Rivers, lakes & sea = 5.8%
• Hills & fields = 4.4%
Outdoor location?

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• Light walking = 86.1%
• Sitting = 81%
• Horticulture = 5.1%
• Hiking = 2.2%
• Running = 2.2%
• Building a shelter = 1.5%
• Canoeing, sailing, kayaking = 1.5%
• Climbing = 1.5%
• Football* = 1.5%
• Basketball* = 0.7%
• Cycling* = 0.7%
• Wilderness expeditions & camping = 0.7%
• Yoga & Tai Chi* = 0.7%
Outdoor activities?

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• Client engagement = 80.3%
• Physical distancing during the Covid-19 pandemic = 47.5%
• Behavioural activation = 41.6%
• Stabilisation exercises/coping skills = 28.5%
• Incorporating physical movement = 27%
• Incorporating nature connection = 22.6%
• Exposure therapy* = 5.8%
• Behavioural experiments* = 4.4%
• To increase confidentiality* = 2.2%
Why outdoors?

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Were you offering outdoor therapy prior to
the Covid-19 pandemic?
Yes = 54%
No = 46%

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• Concerns about confidentiality, risk, boundaries, unwanted attention = 77.2%
• Lack of access to safe and appropriate outdoor spaces = 57.7%
• Lack of policy and guidance within the profession = 54.4%
• Poor fit within my organisational culture = 44.2%
• Lack of experience and training = 39.5%
• Lack of support from colleagues, managers and supervisors = 38.6%
• Time constraints = 19.5%
• Not previously considered it = 14%
• Poor fit with my client group = 11.6%
• Poor fit with therapy approach/ modality/ traditions = 7.4%
• Inclement weather* = 6.5%
• Lack of empirical evidence = 5.1%
Barriers?

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Years qualified .20**
Confidence in therapy .20**
# of clients in a typical day .07
Physical activity level .11
Amount of outdoor leisure time .23***
Nature connectedness .18**
Affective attitudes (TPB) .24***
Instrumental attitudes (TPB) .36***
Injunctive norms (TPB) .52***
Descriptive norms (TPB) .43***
Self-efficacy (TPB) .57***
‘Meeting with
clients outdoors’:
Correlations
* p < .05
** p < .01
*** p < .001

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95% Confidence
Interval
∆R2 B β t Lower
bound
Upper
bound
Step 1 .11***
Outdoor leisure time per week .22 .23 3.55*** .10 .34
Nature connectedness .06 .21 3.12** .02 .10
Step 2 .50***
Outdoor leisure time per week .10 .10 2.27* .01 .18
Nature connectedness .00 -.01 -0.21 -.03 .03
Affective attitudes -.11 -.07 -0.83 -.36 .15
Instrumental attitudes .58 .39 4.63*** .33 .82
Injunctive norms .13 .10 1.64 -.03 .29
Descriptive norms .13 .10 1.70 -.02 .28
Self-efficacy .41 .36 4.67*** .24 .59
Controllability .03 .03 0.47 -.10 .16
Intention to engage in outdoor therapy
(HMR)

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95% Confidence Interval
∆R2 B β t Lower bound Upper bound
Step 1 .09***
Outdoor leisure time per week .13 .22 3.26** .05 .20
Years qualified .02 .18 2.73** .01 .04
Step 2 .32***
Outdoor leisure time per week .06 .11 1.86 -.01 .13
Years qualified .01 .12 2.14* .01 .03
Affective attitudes -.13 .-.13 -1.34 -.32 .06
Instrumental attitudes .18 .20 1.92 -.01 .37
Injunctive norms .21 .26 3.30** .08 .33
Descriptive norms .02 .02 0.30 -.10 .13
Self-efficacy .16 .23 2.39* .03 .30
Controllability .06 .09 1.12 -.04 .16
Step 3 .01
Outdoor leisure time per week .06 .09 1.64 -.01 .12
Years qualified .02 .13 2.23* .01 .03
Affective attitudes -.12 -.12 -1.26 -.32 .07
Instrumental attitudes .15 .16 1.45 -.05 .34
Injunctive norms .20 .25 3.15** .07 .32
Descriptive norms .01 .01 1.41 -.11 .12
Self-efficacy .14 .19 1.88 -.01 .28
Controllability .05 .08 1.06 -.05 .15
Intention .07 .11 1.26 -.04 .17
Engagement in outdoor therapy (TPB)

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• Experiences of outdoor working have doubled during the pandemic:
• Pre-pandemic = 34% (n = 74)
• During-pandemic* = 64% (n = 137)
• The majority of CPs still rarely use outdoor environments (never or rarely
= 67%)*
• Of those who do, the majority walk or sit in public parks.
• The majority go outdoors for client engagement and behavioral activation.
• Main barriers include concerns about confidentiality and a lack of access.
• Outdoor practice is influenced by self-efficacy, instrumental attitudes,
years qualified and injunctive norms.
In summary…
* NB: Data was collected between August and October 2021

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Future research/considerations..
• Will the pandemic have a lasting impact?
• Still more understanding needed on when best to
incorporate outdoor therapy (e.g., client formulation)
• Exploring other functions of outdoor therapy
• Refugees and supporting place attachments

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Safe
Uncertainty
Certainty
Unsafe Mason (1991)
Cooley et al (2022)