'Better Out Than In' – working therapeutically outside

Much of the task of psychoanalytic therapy is about bringing more awareness to the unconscious fantasy of the client’s internal world. Traditional technique has preferred to reduce the amount of external ‘reality’ that could impinge on that process. The so-called ‘blank screen’ manifests in neutral settings and minimal therapist disclosure. Since the start of the Covid-19 pandemic, many clinicians have been forced to accept a much less managed situation. An enforced transition has required many therapists to adapt fundamental characteristics of their frame. Many have found ways to make this work well enough, and it has driven a groundswell of practitioners exploring ways to work outside a traditional frame for the long-term.

Given the ‘safest’ place to be with someone in the current global pandemic is an outdoor space, many more therapists have been considering going outside as a realistic alternative to working indoors or online. In moving to an outdoor space, a different kind of potential emerges. Nature offers an external reality of a different kind. Metaphor, symbolisation, interpretation and meaning-making opportunities are abundant in organic outdoor environments. A client’s movements and physicality may give us clues about other things that are going on. We can notice areas they are drawn to, stay, or avoid in the physical world, and what this might tell us about their psychic landscape. How they relate,
or do not, to external, natural objects, animate or inanimate, may allude to their experiences of object relating or attachment. The following vignette briefly introduces the approach:

Our setting is a walled garden nested in a large park. Formal gardens are remnants of a long-demolished mansion house, previously converted into an asylum for the mentally ill. The client is in his early twenties. He was adopted at six months to join a sibling group already removed due to their mother’s neglect and drug use. Their adoptive parents were emotionally and, occasionally, physically abusive. He has diagnoses of borderline personality disorder and complex PTSD. I meet him weekly at a gated entrance which is the threshold we cross to mark the sessions beginning. Today is bright, fresh and cold in the shade. We walk side by side for a while; it feels like patrolling the walled perimeter. I notice he sounds stilted in his narrative, mirrored by an awkward gait, a slight limp. We find a quiet spot to sit today, in the physic garden (an area with herbs and medicinal plants). As we settle here, a robin emerges from the coniferous hedge containing us. It bobs around, pecking at the ground, then retreats to the enclosed branches. He thinks aloud about the way this keeps the robin safe from unknown threats. He likens it to his state of mind. Emerging, then retreating. Not trusting anyone enough to become fully exposed and vulnerable. He describes paranoid fantasies and emotional distance from his partner, who cannot understand.

He says the paranoid thoughts create tension which manifests in back pain – the limp. I reflect on the aggressively territorial robin, driving away intruders. I wonder if perhaps closeness and intimacy feel like an intrusion to him; a threat. With the gentle crunch of gravel, a couple walk past us, he pauses to let them, as we had agreed to do in our contracting. He refocuses and considers: ‘The robin could stay safe in there forever. But then it would starve to death.’

An abundance of literature on the inherent psychological and physical health benefits of spending time outdoors is evident. Yet theoretical, ethical and practical elements of working psychotherapeutically outdoors also need due consideration. It is not just a case of stepping outside; or just going for a walk in a local park, or a nearby wood. The accessible outdoors extends to forests, hills, rivers and oceans, mountains and wilderness. There is a long-standing tradition of psychological growth and therapy outdoors. This is reflected in decades of developments in adventure therapy, wilderness therapy and nature therapy. Yet, the current enthusiasm of different professional sectors for getting outdoors risks being overshadowed by unethical and ill-informed practice. Unfortunately, this potential has only been accelerated with COVID-19.

The Institute for Outdoor Learning (IOL) is the professional body for individuals and organisations that offer outdoor and adventure experiences that benefit others. In response to the combined concerns and growing interest, IOL published a ‘Statement of Good Practice’ for outdoor therapy. The intention of the guidance is to ask some fundamental questions of practitioners and organisations: are their approach, competence, skills, and abilities appropriate to offer psychological interventions outdoors? The statement recognises knowledge, training and experience of two distinct yet complementary professions operating across two axes – the outdoors and psychological therapies/psychology. The different combinations that can be evident across applied practices are reflected in the ‘Outdoor Mental Health Interventions Model’ (Richards, Hardie and Anderson, 2019). Here, any outdoor therapeutic approach can plot itself against professional competencies on both axes. In so doing practitioners can articulate their work within a specifically defined zone of practice. Three zones are identified as follows:

Zone 1: Outdoor Engagement: adding a psychological or outdoor dimension to enrich the experience provided by a session or service.

Zone 2: Therapeutic Enhancement: using complementary outdoor activities and psychotherapeutic practices to enhance the approach and benefits offered.

Zone 3: Integrated Outdoor Therapy: integrating professional competences in both outdoor learning and psychological therapy to provide unique and dynamic interventions.

The earlier vignette represents a Zone 1 approach. Relating practices to a recognised framework enables greater understanding amongst professional networks. It better communicates the intentions and rationale for work outdoors. The IOL statement intends to celebrate a breadth of practice. It emphasises the possibility for collaboration through creative partnerships and seeks to encourage interdisciplinary dialogue across professional boundaries. You are invited to use the resource when considering this approach with
clients. The more that do, the more consistency will emerge in defining and communicating the boundaries of working psychotherapeutically outdoors.

Andy Hardie: Psychodynamic Counsellor, Supervisor and Clinical Manager for Venture Trust, pioneering an outdoor therapy service with complex and forensic clients in Edinburgh.

Kaye Richards (Dr): Chartered Psychologist, qualified outdoor professional, experienced researcher, and Senior Lecturer in Psychology at Liverpool John Moores University

Neal Anderson: Professional Standards Manager for the Institute for Outdoor Learning and a UKCP-Registered Psychotherapist and Supervisor.