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Adult Clients' Experience of Walk-and-Talk Therapy

Walden Dissertations and Doctoral Studies

Walden University

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Walden Dissertations and Doctoral Studies

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2019

Adult Clients' Experience of Walk-and-Talk

Therapy

Denice Crowe Clark

Walden University

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Walden University

College of Social and Behavioral Sciences

This is to certify that the doctoral dissertation by

Denice Crowe Clark

has been found to be complete and satisfactory in all respects,

and that any and all revisions required by

the review committee have been made.

Review Committee

Dr. Rebecca Stout, Committee Chairperson, Human Services Faculty

Dr. Mary Bold, Committee Member, Human Services Faculty

Dr. Randy Heinrich, University Reviewer, Human Services Faculty

Chief Academic Officer

Eric Riedel, Ph.D.

Walden University

2019

Abstract

Adult Clients’ Experience of Walk-and-Talk Therapy

Denice Crowe Clark

MFT, Mercer University School of Medicine, 2008

BS, University of South Carolina, 1986

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Human Services

Walden University

May 2019

Abstract

Standards of healthcare exist to promote beneficent treatment; however, treatment

approaches are sometimes not supported by research, creating potential ethical issues for

clinicians expected to use evidence-based practices. For example, walk-and-talk therapy,

where therapy sessions incorporate physical activity in an outdoor setting, is being

offered at increasing rates, but research regarding the practice is sparse and primarily

reflects the therapists’ experiences. Thus, the purpose of this interpretative

phenomenological analytic study was to explore the clients’ experience of the altered

frame of walk-and-talk therapy through the conceptual lenses of therapeutic frame and

the biopsychosocial model of well-being. Data were collected through in-depth,

semistructured interviews with a sample of three former walk-and-talk therapy clients,

and data were analyzed using the modified van Kaam method. Findings included that the

clients’ experience of walk-and-talk therapy was shaped by prior therapy experiences

with participants reporting concerns and benefits related to the altered frame. Clients

found walk-and-talk equally or more therapeutic than traditional therapy and felt walk-

and-talk could be a less stigmatizing therapeutic alternative for individuals who find

traditional, indoor therapy unappealing. Implications for social change include shaping

standard practices of walk-and-talk therapy, thus informing the future of training and

supervision as well as providing an alternative therapeutic offering for individuals who

find traditional, indoor therapy unappealing.

Adult Clients’ Experience of Walk-and-Talk Therapy

Denice Crowe Clark

MFT, Mercer University School of Medicine, 2008

BS, University of South Carolina, 1986

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Human Services

Walden University

May 2019

Dedication

I would like to dedicate this dissertation to all those who have loved and

supported me, and cheered me on throughout this process. First, thanks to my husband,

Mark, who has put up with my stress and crazy for a lot of years, but particularly these

last couple of years of dissertation writing. Thank you for the constant reminders to focus

on what is most important and finish! Second, thanks to my youngest daughter, Hope,

who lived at home long enough to experience the majority of the same stress and crazy.

No wonder you moved out when you did. Thanks to my oldest daughter, Grace for

cheering from afar, as well as your daily inquiry towards the end of the dissertation

writing, “Are you done yet?” You were certainly brave to move back home while I was

in those final stages of writing. Apologies to my son-in-law, Allan, for stressing you out

with my writing deadlines, but, thanks for keeping the “pantry” stocked. I would also like

to dedicate this to my grandson, Alex, and granddaughters on the way, Evelyn and Iris.

Let this serve as an example that persistence pays off. Always follow your passions and

live life with purpose. Thanks to my constant canine companion, Beau, who snuggled

next to me from the very first course through the last iteration of this dissertation. Last,

but certainly not least, this is dedicated to my biggest cheerleader, my Mommy, Annette.

You always believed in me and pushed me to excel in whatever endeavors I engaged. I

am proud to be a first generation college graduate, and now a first generation PhD! All of

you share in my success and I could not have done it without you. I love you all. First

round is on me!

Acknowledgments

Many thanks to everyone who held me accountable and guided me through this

journey. Thank you to my committee chair, Dr. Rebecca Stout. Even though you were

assigned as my chair without a prior conversation or introduction, I could not have

selected a more appropriate fit. Thank you for fielding my e-mails and questions so

quickly, and for responding to my discouragements along the way with positivity and

affirmation. Thanks also, to my second committee member, Dr. Mary Bold, for

reminding me to maintain a stance of curiosity, embody the role of researcher, and

exercise brevity in my writing. Finally, thank you to my URR and third committee

member, Dr. Randy Heinrich, particularly for your recommendation on data analysis

method. I had the best dissertation committee in the history of dissertation committees!

Many thanks, also, to my study participants.

I would also like to acknowledge colleagues past and present who served as both

friends and mentors: Alan Lyme, for constantly reminding me of the goal I was pursuing

while also keeping my ego in check; Bonnie Cole Gifford, for your friendship and

inspiring me to find and follow my passion, and to learn it inside-out; Annie Biers, for

your ongoing friendship and affirmation. Thank you, Dr. Aaron Johnson, Dr. Paul Seale,

and Dr. Sylvia Shellenberger, for all the professional opportunities you afforded me these

past several years. And finally, thank you, Deborah Wight-Knight, for holding a safe

space for me all those years ago, and helping me realize the path to finding my passion

and purpose.

Table of Contents

List of Tables ..................................................................................................................... vi

Chapter 1: Introduction to the Study....................................................................................1

Background ....................................................................................................................2

Problem Statement .........................................................................................................4

Purpose ...........................................................................................................................5

Research Question .........................................................................................................6

Conceptual Framework ..................................................................................................6

Nature of the Study ........................................................................................................8

Operational Definitions..................................................................................................8

Assumptions ...................................................................................................................9

Delimitations ................................................................................................................10

Limitations ...................................................................................................................11

Significance..................................................................................................................12

Summary ......................................................................................................................13

Chapter 2: Literature Review.............................................................................................14

Introduction ..................................................................................................................14

Literature Search Strategy............................................................................................16

Conceptual Framework ................................................................................................16

Physical Activity..........................................................................................................19

Benefits of Physical Activity ................................................................................ 19

Mental/Emotional Benefits of Physical Activity .................................................. 23

Other Benefits of Physical Activity ...................................................................... 24

Mediating Factors Related to Benefits of Physical Activity................................. 25

Traditional Therapy .....................................................................................................27

Benefits of Therapy............................................................................................... 28

Frame of Traditional Therapy............................................................................... 28

Barriers to Seeking Psychotherapy ....................................................................... 33

Physical Activity, the Body, and Therapy ...................................................................35

Physical Activity as an Adjunct to Therapy/Counseling ...................................... 36

Including Physical Activity in Therapy ................................................................ 37

Nature Exposure...........................................................................................................41

Benefits of Nature Exposure ................................................................................. 42

Types of Nature-Based Therapies......................................................................... 45

Frame of Nature Therapy...................................................................................... 49

Mediating Factors of Nature-Based Therapy........................................................ 51

Walk-and-Talk Therapy...............................................................................................53

Early Adopters ...................................................................................................... 54

Current Practice .................................................................................................... 54

Therapists’ Perspective of Practice ....................................................................... 55

Clients’ Perspective of Practice ............................................................................ 61

Frame of Walk-and-Talk Therapy ........................................................................ 62

Literature Analysis.......................................................................................................63

Summary ......................................................................................................................66

Chapter 3: Research Method..............................................................................................67

Introduction ..................................................................................................................67

Research Design and Rationale ...................................................................................67

Research Question ................................................................................................ 67

Research Tradition ................................................................................................ 68

Role of Researcher .......................................................................................................70

Methodology ................................................................................................................72

Participant Selection Logic ................................................................................... 72

Instrumentation ..................................................................................................... 77

Procedures for Recruitment, Participation, and Data Collection .......................... 80

Data Analysis Plan................................................................................................ 81

Issues of Trustworthiness.............................................................................................83

Credibility ............................................................................................................. 83

Transferability....................................................................................................... 85

Dependability........................................................................................................ 86

Confirmability....................................................................................................... 87

Ethical Procedures .......................................................................................................88

Summary ......................................................................................................................90

Chapter 4: Results ..............................................................................................................92

Introduction ..................................................................................................................92

Setting. .........................................................................................................................93

Demographics ..............................................................................................................94

iii

Data Collection ............................................................................................................95

Data Analysis ...............................................................................................................96

Evidence of Trustworthiness........................................................................................97

Credibility ............................................................................................................. 97

Transferability....................................................................................................... 98

Dependability........................................................................................................ 98

Confirmability....................................................................................................... 99

Results. .........................................................................................................................99

Participant A Textural Description ..................................................................... 101

Participant B Textural Description ..................................................................... 106

Participant C Textural Description ..................................................................... 111

Participant A Structural Description ................................................................... 117

Participant B Structural Description ................................................................... 117

Participant C Structural Description ................................................................... 118

Composite Textural-Structural Description ........................................................ 119

Summary ....................................................................................................................127

Chapter 5: Discussion, Conclusions, and Recommendations ..........................................128

Introduction ................................................................................................................128

Interpretation of the Findings.....................................................................................129

Findings in Relation to Conceptual Lens............................................................ 134

Summary of Findings.......................................................................................... 136

Limitations of the Study.............................................................................................136

Recommendations for Future Research .....................................................................137

Implications................................................................................................................137

Positive Social Change ....................................................................................... 137

Theoretical Implications ..................................................................................... 138

Recommendations for Practice ........................................................................... 138

Conclusion .................................................................................................................139

References ........................................................................................................................140

Appendix A: Interview Schedule.....................................................................................160

Appendix B: Horizontalization Samples .........................................................................161

List of Tables

Table 1. Invariant Constituents ....................................................................................... 100

Chapter 1: Introduction to the Study

Although counselors and therapists have transitioned from a Freud-led,

psychoanalytic model of the client reclining on a sofa with therapist sitting out of sight to

a model where client and therapist sit face-to-face across the room, therapy generally

continues to occur in an enclosed, office space apart from interruption or outside

distraction (Hooley, 2016; Jordan & Marshall, 2010). Even though therapists have

adapted and changed therapy theories, techniques, and modalities over time, the context

is framed by a structure to enforce ground rules and therapeutic boundaries (Hooley,

2016; Jordan & Marshall, 2010; Langs, 1979). However, some therapists have altered the

context and frame of therapy by taking therapy outdoors and incorporating activity in the

form of running therapy (Hays, 1994; Hays, 1999; Kostrubala, 1976; Kostrubala, 2013;

Kottler & Carlson, 2003), or interaction with nature during the course of nature therapy,

ecotherapy, or wilderness therapy (Jordan, 2013; Jordan, 2015). Many therapists have

also begun engaging clients in walk-and-talk therapy as they have discovered the overall

health benefits of physical activity and exposure to nature and as they sought to engage

clients in a more interactive and dynamic therapeutic experience (Jordan, 2014; Jordan &

Marshall, 2010).

In this chapter, I introduce the background of walk-and-talk therapy, including the

addressed problem and purpose of this study. In addition, I present the research question

and the conceptual framework through which I approached this study. I describe the

research tradition and define important terms, as well as outline assumptions,

delimitations, and limitations. Finally, I describe the significance of this study.

Background

Physical activity has been correlated with improvements not only in physical

health but also overall mood and well-being (Blair, Salis, Hutber, & Archer, 2012; Carek,

Laibstain, & Carek, 2011; Smith, 2015). For this reason, mental health professionals

frequently prescribe exercise as an adjunct to psychotherapy (Howell, Passmore, &

Holder, 2016; Smith, 2015). Exposure to nature via nature therapy, ecotherapy, or

wilderness therapy has also been positively correlated with improvements in mood and

well-being (Chalquist, 2009; Jordan, 2015; Stigsdotter et al., 2011). The combination of

walking in natural settings versus walking in more urban settings has been related to even

greater improvements in mood (Bratman, Daily, Levy, & Gross, 2015). Thus, traditional

psychotherapy has been combined with walking in an outdoor setting so walk-and-talk

therapy may provide additional therapeutic benefits for mood and overall well-being for

clients (Greenleaf, Bryant, & Pollack, 2014; Revell & McLeod, 2017).

Walk-and-talk therapy, where therapist and client engage in talk therapy while

walking side-by-side in an outdoor setting, has increased in popularity and has caught the

attention of the popular press (Abcarian, 2017; Chillag, 2017; English, 2015; Knox, 2017;

Magner, 2017; Maher, 2017; Maxted, 2017; Neely, 2017; Packhams, 2015; Wright,

2008). The practice is not entirely new, as Freud was rumored to walk and talk with his

clients through the streets of Vienna (Jordan & Marshall, 2010; Karp, 2011), and in the

1970s, Kostrubala (1976) developed a training program for therapists incorporating

running with clients to improve mental health diagnoses. In the decades since Kostrubala

began running therapy training, a few clinicians have used running or walking with

clients (Gontang, 2009; Hays, 1994; Kottler & Carlson, 2003), and increasingly more

therapists are offering walk-and-talk therapy as an alternative to traditional, in office,

face-to-face therapy (DeAngelis, 2013).

Research regarding number of therapists incorporating physical activity into their

therapy sessions is scarce (DeAngelis, 2013), and the number of therapists offering walk-

and-talk therapy is unknown. But there are many media reports referencing the expansion

of walk-and-talk therapy and suggest an increase in implementation (Abcarian, 2017;

Chillag, 2017; English, 2015; Knox, 2017; Magner, 2017; Maher, 2017; Maxted, 2017;

Neely, 2017; Packhams, 2015; Wright, 2008). However, peer-reviewed research and the

work of master’s and doctoral students specific to walk-and-talk therapy is minimal and

is focused on therapists’ experiences of the practice rather than clients’ experiences

(Charbonneau, 2016; Jordan, 2013, 2014; Jordan & Marshall, 2010; King, 2015;

McKinney, 2011; Revell, 2016; Revell & McLeod, 2017).

Although some therapists have employed outdoor therapy spaces that mirror

indoor spaces in terms of a demarcated walled space (Jordan, 2015), most walk-and-talk

clinicians believe in the added therapeutic benefit of moderate exercise during the

session. Many walk-and-talk counselors are physically active themselves and claim to

have personally experienced the overall health benefits afforded by exercise (DeAngelis,

2013; Jordan, 2013, 2015). For this reason, incorporating physical activity in therapy

rather than prescribing it as an adjunct to traditional talk therapy sessions felt like a

natural fit to these practitioners.

Despite efforts to improve treatment for disorders like depression and anxiety in

industrialized nations (Jorm, Patten, Brugha, & Mojtabai, 2016), and increased rates of

treatment seeking for psychological issues between 2001-2012, residents of the United

States have continued to suffer from increased mental or emotional distress (Mojtabai &

Jorm, 2015). Possible explanations include poor quality or low intensity treatments,

treatments that were not appropriately targeted to the individual, or inefficient use of

treatment options often resulting from disparities in access to services (Mojtabai & Jorm,

2015). Thus, walk-and-talk therapists believe that incorporating physical activity and

nature into their traditional therapy offerings is an outgrowth of client needs (McKinney,

2011) and may be a better fit for clients not comfortable in traditional therapy settings

(Bell, Foley, Houghton, Maddrell, & Williams, 2018; Houghton & Houghton, 2015),

which may close the gap of ill-fitting or poor quality treatment options as well as

treatment disparities (Mojtabai & Jorm, 2015). Taking therapy outside the confines of a

secure, confidential, walled space, however, may present new challenges. For this reason,

it was important to understand how clients experience this change in context of therapy.

Problem Statement

Although therapists who believe in the healing benefits of exercise and nature

exposure are conducting their client sessions in more natural settings at increasing rates

(Jordan, 2015), there is a lack of research regarding the practice, especially on clients’

perspectives. This creates concern for therapists expected to use evidence-based practices

and avoid practices that could cause harm to their clients (i.e., maleficence; American

Association for Marriage and Family Therapy [AAMFT], 2016; American Psychological

Association [APA], 2010). Taking therapy outside the traditional office space into more

natural settings changes not only the physical setting but may also create ethical

considerations (Hooley, 2016; Reese, 2016); therefore, it was important to research walk-

and-talk therapy further to understand more about the practice and clients’ experiences of

it. Thus, this study addressed the problem of avoiding treatment that does not help clients

and avoiding potential harm to these clients as the result of participation in an invalidated

therapeutic practice (i.e., walk-and-talk therapy). Gaining an understanding of clients’

perspectives of the practice may establish whether walk-and-talk therapy is as beneficial

as traditional talk therapy and may serve to shape future walk-and-talk therapy guidelines

for beneficent practice, training, and supervision.

Purpose

Because of the lack of research regarding walk-and-talk therapy, it was important

to gain a better understanding of the practice. Although the current literature on walk-

and-talk therapy from therapists’ perspectives is informed by input from their clients

(Jordan, 2015), the lack of research specific to clients’ perspectives presents a gap in the

current knowledge base. Further, conducting therapy in outdoor settings may alter the

experience of the processes and some aspects of therapy like confidentiality, potentially

creating ethical issues (Hooley, 2016). Thus, I conducted this qualitative study to gain a

better understanding of adult clients’ lived experiences (Merriam & Tisdall, 2016;

Moustakas, 1994) of walk-and-talk therapy, using an interpretative phenomenological

analysis (IPA) approach (Brocki & Wearden, 2006; Reid, Flowers, & Larkin, 2005;

Smith, Flowers, & Larkin, 2009). The objectives were to better understand clients’

experiences of walk-and-talk therapy and to determine whether there were any aspects of

the altered frame of walk-and-talk therapy that clients found helpful or harmful. In

addition, I hoped to determine potential areas of focus for future research regarding

efficacy of walk-and-talk therapy and the avoidance of maleficence.

Research Question

The overarching research question for this study was, “How do adult clients

experience talk therapy conducted while walking side-by-side with their therapist in an

outdoor setting?”

Conceptual Framework

Therapeutic frame is defined as the physical setting, boundaries, roles, and

expectations of client and therapist, including the relationship that is built between

therapist and client that gives structure and creates expectations regarding power

differentials, authority, and expertise wherein the clinician treats the client (Jordan, 2013;

Jordan & Marshall, 2010; Langs, 1979). The conceptual framework that guided this study

was how the frame of therapy influenced the experience of the client during the

therapeutic process (Jordan & Marshall, 2010; Jordan, 2015). The interplay of the

physical, mental, and social aspects of walk-and-talk therapy mirror the biopsychosocial

model of health (Wade & Halligan, 2017); therefore, I also used the biopsychosocial

model as a lens to view the therapeutic frame of walk-and-talk therapy.

Therapy is typically conducted in an enclosed setting in which aspects of the

session, such as assurance of privacy and confidentiality, are controlled and monitored by

the therapist and ensured by the physical setting (Jordan, 2015). Roles and expectations

are understood given the frame and the enclosed space is considered the territory of and

controlled by therapist (Casement, 2014; Milton, 1993; Jordan, 2014). Clients normally

go to traditional psychotherapy for therapists’ expertise and expect to be treated by the

therapist.

Engaging in walk-and-talk therapy in an outdoor setting where some physical

boundaries are removed or conditions of the therapy session are unpredictable can both

enhance or compromise the therapeutic experience for clients and therapists alike

(Jordan, 2015; Jordan & Marshall, 2010; King, 2015; McKinney, 2011; Revell &

McLeod, 2016). According to walk-and-talk therapists, walking side-by-side outdoors

levels any power differential as neither client nor therapist possess any control over the

environment (Jordan, 2015; Jordan & Marshall, 2010). Negotiating the unpredictability

of setting, including weather and other people co-occupying the outdoor therapy space,

creates additional uncertainties that further alter the context and experience of therapy.

Clients conavigating these differences may, therefore, take greater ownership of the

therapy session and any power differential normally experienced in indoor therapy may

be lessened thereby potentially changing therapy dynamics (Jordan, 2015; King, 2015;

McKinney, 2011).

Although primarily aimed at addressing psychological concerns, walk-and-talk

therapists approach treatment from a perspective more akin to the biopsychosocial model

by incorporating physical activity and nature exposure into their psychotherapy sessions.

Changing the setting/context and altering the therapeutic frame may then create a new

experience for clients. Introducing the additional physical components of exercise and

nature exposure within the frame of walk-and-talk therapy may alter the clients’

perceptions of how these differences contribute to the therapeutic process or to subjective

overall well-being. Therefore, with a qualitative, IPA approach, I explored the clients’

overall experience of walk-and-talk therapy through a conceptual framework of

therapeutic frame and biopsychosocial well-being.

Nature of the Study

Qualitative inquiry is designed to gain an in-depth understanding of a

phenomenon, event, process, or the lived experience of individuals (Maxwell, 2005;

Merriam & Tisdell, 2016; Moustakas, 2014). This study was conducted to understand in-

depth adult clients’ lived experiences of the phenomenon of the altered frame of walk-

and-talk therapy. Because walk-and-talk therapy is a novel approach to psychotherapy,

and the research that I was able to locate was limited and specific to therapists’

perspectives, I chose a qualitative approach for a better understanding of adult clients’

experiences of the frame of walk-and-talk therapy (Maxwell, 2005; Moustakas, 2014;

Patton, 2015). A qualitative, IPA inquiry allowed for in-depth exploration of their

experiences, including exploration of the context of the outdoor setting coupled with

physical activity (Maxwell, 2005; Patton, 2015). Further information regarding the IPA

approach is provided in Chapter 3.

Operational Definitions

Frame of therapy: The context, setting, and/or physical boundaries of the therapy

session that establish the rules of engagement for therapy to include the relationship

between client and therapist (Jordan, 2013; Jordan & Marshall, 2010; Langs, 1979).

Nature therapy: Exposure to nature/natural settings intended to decrease stress,

improve relaxation, as well as reduce the toll of artificial and/or toxic physical stimuli

(Li, 2018; Miyazaki, Park, & Lee, 2013).

Therapist: A licensed counselor, therapist, psychologist, social worker, or other

licensed mental health provider (Hunter & Goodie, 2010; Smith, 2017).

Therapy: Treatment conducted by a licensed clinician typically involving

conversational sessions (e.g., “talk therapy”) between client and therapist for helping

clients navigate and ideally realize improvement in mental, emotional, and/or behavioral

issues (Smith, 2017). Additionally, it is called counseling or psychotherapy.

Walk-and-talk therapy: Therapy sessions conducted in an outdoor/natural setting

where client and therapist walk side-by-side during the encounter (Jordan, 2015; King,

2015; McKinney, 2011).

Assumptions

I expected that study participants would be volunteers, participating of their own

free will and that they would give accurate and honest descriptions of their participation

in walk-and-talk therapy. Furthermore, I assumed that these participants’ experiences,

input, and responses would be genuine and valuable toward understanding in greater

depth the practice of walk-and-talk therapy. I also assumed that the research question

would elicit an accurate understanding of clients’ experiences of the frame of walk-and-

talk therapy and that study participants would be able to accurately articulate their

understanding of the frame of walk-and-talk therapy sessions and its impact on their

overall experience of therapy.

Delimitations

The focus of this study was limited to gaining a general understanding of clients’

experiences of walk-and-talk therapy defined as talk therapy occurring in a natural setting

while therapist and client walk side-by-side. This investigation did not include

examination of the therapeutic frame of other types of nature-based or ecotherapy that

include more intense interaction with nature and/or overcoming challenges or obstacles

presented by intensive nature outings as is often encountered in wilderness therapy

(Hoag, Combs, Roberts, & Logan, 2016; Tucker, Norton, DeMille, & Hobson, 2016).

Rather, the focus was how clients experienced the unbounded outdoor environment

combined with moderate physical activity by walking while also participating in

traditional talk therapy. I did not delve into nor compare therapeutic modality (i.e.,

cognitive behavioral therapy versus psychoanalytic) used by the walk-and-talk therapists;

the focus was on clients’ perspectives of the frame regardless of therapeutic modality.

Furthermore, findings were bounded by the characteristics of a small number of former

walk-and-talk client participants who participated in therapy for mild to moderate

psychological issues (e.g., depression, stress, anxiety, grief). These clients’ symptoms

may have met criteria for diagnosis, but symptoms were manageable with limited

impairment in daily functioning and clients did not pose a danger to themselves or others

at the time of therapy nor at the time of participation in this study (American Psychiatric

Association [APA], 2013). Participants also resided in the United States and in areas with

milder weather conditions. As a result of these delimitations, findings regarding clients’

perspectives of the frame of therapy may differ from walk-and-talk therapy clients with

either more severe issues and/or those who participate in walk-and-talk therapy in areas

with more severe weather conditions.

Limitations

There are risks associated with conducting qualitative inquiry related to validity

because of generalizability (Maxwell, 2005). Internal generalizability may be problematic

if the researcher only focuses on similarities between participant interview responses and

is not attuned to any variations that arise between them. To increase the validity of this

IPA, it was important for me to be mindful of and note any differences that surfaced from

different client perspectives and between clients who participate in walk-and-talk therapy

with different therapists and/or at different locations. In addition, qualitative research

does not typically lend itself to external generalizability; however, IPA may serve as a

launching point for later theory development (Reid et al., 2005; Smith et al., 2009).

Therapists and clients often have different experiences of therapy (Timulak,

2010). As a walk-and-talk therapist who believes there are synergistic benefits from

combining traditional psychotherapy with walking outdoors, I acknowledged and

managed this known personal bias (see Miles, Huberman, & Saldaña, 2014; Smith et al.,

2009) when collecting and analyzing the data and reporting findings. Managing this

personal bias began at the outset in forming quality, non-leading, open-ended questions

(Smith et al., 2009; Yin, 2014) that allowed for various perspectives and rich descriptions

of the clients’ experience of walk-and-talk therapy. I also listened while avoiding

preconceived ideas of where the research process and questions might lead. As new or

unexpected ideas arose during the data collection and/or analysis phases, I was flexible

and followed these threads where they led. I overtly stated any biases I had, bracketed

them, and was willing to entertain new thoughts and themes (Cooper & McLeod, 2015)

being mindful that some biases would not arise until the data collection and analysis

phases (Smith et al., 2009). I also journaled personal expectations and made notes during

the process of personal perceptions, thoughts, and/or feelings regarding the process and

the content (see Cooper & McLeod, 2015).

Significance

Therapeutic techniques have evolved over time through practice and study.

Although sometimes research precedes practice, many new therapy modalities and

practices are implemented based on therapist and/or client preferences and adjusted over

the course of therapy based on experience and/or research findings (Casement, 2014;

Harvey, 2016). Therapists’ practices are more often informed by supervision feedback

versus research (Gyani, Shafran, Myles, & Rose, 2014); however, supervision for walk-

and-talk therapy does not currently exist because the practice is relatively new and there

are no standards for it (Charbonneau, 2014). Walk-and-talk therapy has evolved over

time as therapists and counselors have believed that adding exercise in a more natural

outdoor setting to their therapy sessions would benefit their clients (Jordan, 2015). For

instance, research has supported the therapeutic benefits of both exercise (Blair et al.,

2012; Carek et al., 2011; Smith, 2015) and nature exposure (Chalquist, 2009; Jordan,

2015; Stigsdotter et al., 2011) separately and synergistically (Bratman et al., 2015;

Shanahan, Fuller, Bush, Lin, & Gaston, 2015). It is important to use evidence-based

practices (AAMFT, 2016; APA, 2010; Gyani et al., 2014) because of standards of care

that are regulated and on which insurance payments are often based (Mechanic, 2012).

Researching clients’ experiences of the frame of walk-and-talk therapy helped

give further understanding and may further define the practice, ensuring that therapists

are providing evidence-based practices and demonstrating sufficient standards of ethical

care. In addition, qualitative inquiry helps shape theory that, in turn, may be tested

through future quantitative inquiry to hone and refine clinical practice (Sofaer, 1999). If

walk-and-talk therapy is later found to be as effective, or more effective as talk therapy

alone, clients may not only experience added psychological benefits by participating in

the practice but also the added physical benefits of physical activity. It may also provide

additional treatment options for clients who may not prefer traditional therapy in an

office setting. Finally, once more is understood about how clients experience the frame of

walk-and-talk therapy including what is helpful or hindering in the experience,

adjustments may be made to maximize therapeutic benefit for the clients.

Summary

This first chapter provided background, and outlined the problem being addressed

and the purpose of the study of walk-and-talk therapy. The research question, research

objectives, and framework were also introduced as part of a qualitative research

approach. Operational definitions were provided for important concepts and terms.

Assumptions, limitations, and delimitations were also described. Finally, the significance

of this study was discussed. The next chapter details findings from the literature review

conducted to determine the gaps in the knowledge base regarding the topic of this study.

Chapter 2: Literature Review

Introduction

According to the National Institute of Mental Health [NIMH] (2018), talk therapy

is a primary treatment for psychological conditions either in combination with

psychotropic medications or as a stand-alone treatment. However, professionals may also

recommend therapeutic lifestyle changes, such as physical activity, for psychological

conditions such as depression or anxiety (Howell et al., 2016; Walsh, 2011). Physical

activity is associated with physiological health benefits (Reiner, Niermann, Jekauc, &

Woll, 2013; Soroush et al., 2013; Sykes, 2009; Warburton, Nicol, & Bredin, 2006) as

well as improvements in psychological well-being (Rot, Collins, & Fitterling, 2009;

Sykes, 2009), especially when physical activity is conducted in a more natural setting

(Mackay & Neill, 2010; Stigsdotter et al., 2011; Wright, 2008). Many therapists who

believe in the benefits of talk therapy and physical activity and nature exposure for

overall well-being are now offering walk-and-talk therapy sessions outdoors as an

alternative to traditional, in-office therapy (Jordan & Marshall, 2010; King, 2015;

McKinney, 2011). These therapists are supporting the idea that well-being comes from

connections to people as well as connections between people and places during particular

times (Rybråten, Skår, & Nordh, 2017, p. 24) and during specific activities (Hays, 1994;

Hays & Sime, 2014; Rahman, El Werfalli, & Lehmann-Waldau, 2017; Vincent 2017).

For the most part, the content and process of walk-and-talk therapy remains the same as

traditional therapy sessions conducted indoors; however, taking therapy outside while

walking together alters the context and frame of therapy (Jordan, 2015; Jordan &

Marshall, 2010).

The practice of taking therapy outside the traditional office space into more

natural settings changes not only the physical setting and therapeutic frame but may also

create ethical considerations (Hooley, 2016; Reese, 2016). Per their professional codes of

ethics, therapists should attempt to abide by the principles of beneficence and avoid

maleficence while providing evidence-based services (AAMFT, 2016; APA, 2010) and

provide services in which they have adequate understanding and training (Duros &

Crowley, 2014). But despite its increasing popularity and use, there is little research

regarding walk-and-talk therapy aside from an older study addressing adolescent client

experiences with walk-and-talk therapy (Doucette, 2004) and a case study involving

incorporating walk-and-talk with a client suffering with complex trauma whose progress

had stagnated with other therapeutic modalities (Wessan, 2018). The remainder of the

research regarding walk-and-talk therapy has been focused on therapists’ perspectives of

the practice. Therefore, the purpose of this study was to gain an understanding of the

clients’ perspective of the practice, which can establish aspects of walk-and-talk therapy

that clients find helpful or hindering and whether the change of therapeutic frame might

create potential harm to the client.

In this chapter I describe the literature search strategy including search terms and

databases used. I describe the conceptual framework of therapy frame and

biopsychosocial model of well-being. I also present literature that addresses the

individual components of physical activity, nature exposure, and psychotherapy, as well

as the literature specific to walk-and-talk therapy. Finally, I discuss the gap in the

knowledge base regarding walk-and-talk therapy including lack of information regarding

the experience of walk-and-talk therapy from the clients’ perspectives.

Literature Search Strategy

This literature review was conducted to examine the current knowledge base

regarding walk-and-talk therapy and the individual components that comprise walk-and-

talk therapy (i.e., physical activity/walking, nature exposure, and psychotherapy) in

addition to determining what aspects of walk-and-talk therapy need further study.

Psychology databases searched included PsycINFO, PsycARTICLES, PsychEXTRA, and

SocINDEX using search terms “walk-and-talk therapy,” “walk and talk therapy,” “walk

talk therapy,” “walk talk counseling,” “walk and talk counseling,” “walking counseling,”

“walking therapy,” “nature therapy,” “outdoor therapy,” “exercise and mental well-

being,” “nature and mental well-being.” An iterative process was used as well in which

reference lists of found articles and dissertations were used to uncover further resources

pertaining to desired subject matter. In addition, U.S. Government and other

academically recognized websites were used for gathering current information, statistics,

and references for the most current research regarding physical and psychological health

and well-being.

Conceptual Framework

The World Health Organization (WHO) defined health as “a state of complete

physical, mental and social well-being and not merely the absence of disease or

infirmity” (WHO, 1948, preamble, bullet 1). Thus, health encompasses not only aspects

that contribute to physical health but also psychological and relational health. In the

United States, however, treatment is usually divided between physical versus

psychological issues (Vanderbilt, Dail, & Jaberi, 2015), despite evidence that an

integrated or biopsychosocial approach is useful for a myriad of healthcare outcomes

(Wade & Halligan, 2017). This segmented health approach was described as a “dualistic

separation of body and mind, nature and culture” (Rybråten et al., 2017, p. 4). Health and

well-being are not experienced apart from environment but rather within and in dynamic

relationship with environment and landscape (Rybråten et al., 2017). Further, there is a

relationship between psychological and physical health wherein stress can create or

compound mental and physical illnesses (Corazon, Nyed, Sidenius, Poulsen, &

Stigsdotter, 2018). Thus, well-being may be understood as a synergistic interplay of

physical, mental, emotional, relational, and environmental factors (Adams & Morgan,

2018; Rybråten et al., 2017) and approaches to health and well-being should address

these aspects; however, Western medicine often has a different approach.

Western physicians typically treat physical ailments with physical interventions

such as alterations in diet, recommendations for regular physical activity, or prescriptions

for medications without addressing underlying or comorbid mental or emotional

contributing factors (Vanderbilt et al., 2015). Clinicians generally treat mental and

emotional issues with psychotherapy and/or psychotropic medications, as there is

evidence for biological processes for these conditions (NIMH, 2018). On occasion,

clinicians may recommend therapeutic lifestyle changes, such as physical activity, as an

adjunct to therapy or medication (Kerling et al., 2015; Kyam, Kleppe, Nordhus, &

Hovland, 2016; Legrand & Neff, 2016), but incorporating physical activity into therapy

sessions was not the norm until more recently.

Evidence supports the healing value of nature and natural surroundings for

physical and mental health (Corazon et al., 2018; Feugen & Breitenbecher, 2018; Iwata et

al., 2016; Korpela, Stengård, & Jussila, 2016), including incorporation of more natural

elements in indoor treatment settings (Gessler, 1992; Ulrich, 1979) and the creation of

outdoor intervention therapeutic programming (Bratman et al., 2015; Ulrich, 1979).

Walk-and-talk therapy combines aspects of these dynamics—physical activity, traditional

psychotherapy, natural setting, and relational interaction between therapist and client—in

a way that may create a new dynamic and a different way in which clients’ perceive their

therapy experience and the altered frame of such (Jordan, 2015; Jordan & Marshall,

2010).

Approaches to health and well-being might be done via multiple means that

include the various biopsychosocial processes as well as considering contextual

components such as environment or the contribution of nature exposure. Therefore, the

conceptual lenses that shaped this study included the biopsychosocial model of well-

being and the frame of psychotherapy, in particular clients’ experiences of the frame

when therapy is conducted outdoors while client and therapist walk side-by-side. I

examined what researchers discovered regarding the components of walk-and-talk

therapy and the overlap of some of these various components and summarized in the

following sections. This helped determine what was known and not known regarding the

dynamic interplay of physical activity, psychotherapy, client and therapist relational

interactions, and nature exposure as it related to overall well-being, including mental and

emotional well-being. Additionally, I reviewed the literature to date regarding the frame

of therapy as well as the practice of walk-and-talk therapy.

Physical Activity

Physical activity has been correlated with many benefits to health and well-being.

Beyond physiological benefits, other benefits of physical activity include increases in

mood and cognition and increased creativity. These benefits, however, may be mediated

by several factors such as level of enjoyment, characteristics of the location or

environment where activity occurred, and social aspects and interactions during physical

activity.

Benefits of Physical Activity

In the United States, efforts to promote public health have included the Surgeon

General’s 2015 Call to Action aimed at promoting disease prevention, encouraging a

healthy lifestyle at every age and across demographics, and establishing healthy,

walkable communities (Murthy, 2017; U.S. Department of Health and Human Services

[HHS], 2015). Lack of physical activity is a public health crisis, and physical activity is

important not only for physical health but for overall well-being (Blair et al., 2012;

Febbraio, 2017; Hanson & Jones, 2015). Lifestyle factors including physical inactivity

have contributed to rising noncommunicable disease rates such as cancer, diabetes, and

cardiovascular disease (Reiner et al., 2013; WHO, 2018) as well as osteoporosis and

osteoarthritis and gender-specific issues such as erectile dysfunction and polycystic ovary

syndrome (Febbraio, 2017). WHO (2018) also described physical inactivity as

contributing to increased early mortality risk with 25% of adults lacking sufficient

healthy activity levels globally. Age-related diseases as well as depression and other

mental health conditions also correlate with level of physical activity (Carrera-Bastos et

al., 2011; Reiner et al., 2013; Rot et al., 2009).

Regular physical activity lowers risk of early death by 30% (HHS, 2015). Adults

meeting regular physical activity recommendations have also experienced better

cardiorespiratory and muscular fitness as well as a lowered risk of a number of specific

conditions including cardiovascular disease and metabolic syndrome (HHS, 2015).

Generally, a minimum of 150 minutes per week of moderately intense physical activity,

or 75 minutes per week of vigorous activity, has been recommended for minimal health

benefits, with 300 minutes per week of moderately intense activity recommended for

maximal health benefits (HHS, 2015; WHO, 2018).

In addition to physical activity recommendations, walking is one of the oldest

forms of physical activity (Solnit, 2014) deemed generally safe and easy for most

individuals (Murthy, 2017; HHS, 2015) and does not require any special equipment or

training (Murthy, 2017; Sykes, 2009). As early as approximately 450 BC, Hippocrates

attributed level of physical activity to physical well-being, likening walking to medicine

(Febbraio, 2017). In the 1960s, a 10,000 steps per day benchmark was established for

adults based on Japanese walking group research outcomes coupled with an advertising

campaign for pedometers (Tudor-Locke, & Bassett, 2004). This 10,000 per day step

measure also correlated with meeting recommended WHO time-based physical activity

guidelines (Wattanapisit & Thanamee, 2017). A review of English-language articles

between 2000–2016 on benefits of adults meeting the recommended 10,000 per day step

goal revealed benefits for health issues including body composition measured by weight

and body fat, bone density, blood pressure, and cholesterol (Wattanapisit & Thanamee,

2017). Interventions aimed at reaching and maintaining the 10,000 step daily goal have

included reinforcement via prizes, gift cards, and other items of value as well as

pedometer-based interventions including those with individualized motivation and

feedback (Wattanapisit & Thanamee, 2017). Additionally, family- and community-based

campaigns with community-based interventions over a 1-year period have resulted in an

8% increase in individuals reaching the targeted 10,000 per day step goal (Wattanapisit &

Thanamee, 2017). Participants across studies have reported walking as an accessible and

popular way in which to achieve physical activity guidelines with little risk of injury

(Wattanapisit & Thanamee, 2017).

Further research has also supported the benefits of walking. In the United

Kingdom, focus group interviews were conducted with three walking groups and their

leaders to determine perceived benefits and sustainability of these groups (Raine,

Roberts, Callaghna, Sydenham, & Bannigan, 2017). Participants reported many

subjective benefits including immediate and longer-term improvement in feelings of

well-being. Participants also reported making additional healthy behavior changes, such

as changes in their diet, because of their engagement in the walking groups (Raine et al.,

2017). Being outdoors and making social connections with others served as added

benefits to well-being as well as reasons participants cited for continued walking group

attendance (Rain et al., 2017). Some walking group participants reported that they also

began incorporating walking and other healthy behaviors with partners, family members,

or friends (Raine et al., 2017). Participants reported that they wished primary care

providers would consider offering walking groups as an alternative to their general

recommendation of a gym membership (Raine et al., 2017). Walking is cost-effective

compared to other types of physical activity, is considered beneficial for overall well-

being, and participants sustained this activity through social interactions and nature

exposure (Raine et al., 2017).

Despite the ease in which individuals can incorporate walking as physical activity

and despite an abundance of knowledge regarding the benefits, Americans walk far less

than in generations past in industrialized nations (Vanderbilt, 2012). For example, a

Canadian Amish group whose labor-intensive, farming lifestyle has remained largely

unchanged was observed in a study using pedometers, and participants averaged step

rates of 18,000 per day (Bassett, Schneider, & Huntington, 2004) versus current average

daily rates for Americans of 5,117 steps (Vanderbilt, 2012). In another study of physical

activity levels of persons participating in a simulated historical lifestyle activity in

Australia, participants averaged walking an estimated 16 kilometers per day, equating to

more than twice that of modern levels of physical activity (Egger, Vogels, & Westerterp,

2001). As adults are less physically active and subsequently suffer from lower overall

fitness, their risk for physical illness rises, but physical activity and fitness can improve

physical health as well as mental and emotional well-being.

Mental/Emotional Benefits of Physical Activity

Physical activity is a beneficial treatment for many noncommunicable diseases

and age-related diseases, and it serves as a preventative measure for mental conditions

(Reiner et al., 2013). Physical activity has been efficacious as a treatment for

psychological issues such as depression (Rot et al., 2009), anxiety (Mackay & Neill,

2010), age-related dementia, and Alzheimer’s disease (Reiner et al., 2013). Exercise has

been positively correlated to mood and cognition improvements with even greater

improvements in mood related to walking/exercising in a more natural setting versus

walking in a more urban setting (Bratman et al., 2015). Physical activity has also been

positively correlated to improvements in symptoms of mild to moderate depression

similar to medication and as an adjunct to psychotropic medications (Carek et al., 2011).

In addition, cardiorespiratory physical fitness has been associated with lower occurrences

of more severe depression or anxiety in a population of adults aged 25-83 regardless of

type of physical activity in which they engaged (e.g., leisure, occupational, or sport;

Baumeister et al., 2017). Individuals who have walked with others versus those who have

not have also experienced improvements in quality of life (Meads & Exley, 2018).

Physical activity has also been associated with hedonic well-being (i.e., positive

affect and avoidance of negative feelings) and eudaimonic well-being (i.e., self-

realization and meaning making; Ettema & Smajic, 2015). Based on research from the

mid-1990s through the middle of the first decade of the 2000s regarding the association

between physical activity and mental/emotional health, physical activity for various age

and gender groups was linked to increases in psychological well-being including

improvements in symptoms of depression similar to improvements with treatment with

antidepressant medication (Carek et al., 2011). Physically inactive individuals were more

likely to develop psychiatric symptoms (Carek et al., 2011). Individuals who participated

in physical activity have reduced use of medications for depression and anxiety, which

reduces the expense associated with medication in addition to reducing severe side effects

associated with psychotropic medications (Carek et al., 2011). Furthermore, trauma

interventionists have often involved physical activity to encourage change in limbic

responses because trauma frequently manifests in physical symptoms (Duros & Crowley,

2014). The literature has thus supported the benefits of physical activity for a variety of

psychological issues as well as overall well-being. Researchers have also identified

additional benefits of physical activity likely of further interest to therapists.

Other Benefits of Physical Activity

Other benefits of physical activity have been discovered, including those reported

from a study designed to test creativity effects of walking versus sitting, and walking

indoors versus outdoors, as well as controlling for exposure to nature (Oppezzo &

Schwartz, 2014). Creativity increased after walking whether indoors or outdoors;

however, participants experienced increased novel thoughts when outdoors and talked

more when walking outside (Oppezzo & Schwartz, 2014). Although focused on business,

work, or school settings (Oppezzo & Schwartz, 2014), the results of this study are

important as clients are often in need of new approaches to their issues. For this reason,

these findings were also important when considering how walk-and-talk therapy might

influence ideas and progress in therapy.

In another phenomenological study on walking, 73 residents of a mid-sized town

in southeastern Norway were interviewed (Rybråten et al., 2017). Participants described

walking as a dynamic experience offering multiple benefits including the opportunity to

experience their surroundings, lose themselves in thought and contemplation, socialize

with others along the way, as well as being a form of transportation from one place to

another (Rybråten et al., 2017). Although walking was a form of exercise, many of the

study participants also mentioned walking at a slower pace was a form of relaxation

(Rybråten et al., 2017). Participants described an experience of place making as they

integrated their surroundings, senses, and subjective experience with the physical activity

of walking (Rybråten et al., 2017).

These findings reflect some of the change clients may experience through adding

physical activity to therapy, such as feeling differently about the efficacy of their therapy

experience and how it influences their overall well-being. They may also feel more open

and creative in exploring and addressing their concerns. There are additional mediating

factors related to individuals’ enjoyment of physical activity.

Mediating Factors Related to Benefits of Physical Activity

Duration and intensity are some of the many mediating factors that appear to

influence the benefits of physical activity (Soroush et al., 2013). Participant level of

enjoyment of the activity influenced participation, long-term follow-through, and short-

and long-term benefits (Ettema & Smajic, 2015; Raine et al., 2017). Other mediating

factors included having safe spaces for physical activity (Ettema & Smajic, 2015; Grant,

Pollard, Allmark, Machaczek, & Ramcharan, 2017; Rybråten et al, 2017), having

stimulating environments (Ettema & Smajic, 2015; Grant et al., 2017), as well as having

sufficient level of greenness or natural surroundings (Ettema & Smajic, 2015; Raine et

al., 2017). Social context was also important as individuals reported greater enjoyment

and well-being (Grant et al., 2017; Meads & Exley, 2018; Rybråten et al., 2017), as well

as sustained participation when being physically active with others (Raine et al., 2017).

Although older individuals cited health as the main reason to join a walking group, social

relationships built during group walks influenced continued participation (Grant et al.,

2017).

Individuals often walk alone by choice but sometimes out of necessity (Rybråten

et al., 2017). Loneliness is considered a current public health dilemma and walking solo

was viewed as a lonely endeavor (Rybråten et al., 2017). To counter the loneliness,

individuals assigned a specific purpose to their walks (Rybråten et al., 2017). Participants

viewed walking solo positively when it was for reflection and restoration within the

context of and in dynamic relationship with the landscape and surroundings (Rybråten et

al., 2017). Frequently individuals preferred walking with others for companionship while

simultaneously processing life and meaning (Rybråten et al., 2017). Males aged 40-50

felt less positively about walking when there were other transportation options, and

desired to walk with others only if there was an associated purpose or destination

(Rybråten et al., 2017). However, as men aged they considered walking with others

important for health and social connection (Rybråten et al., 2017).

The literature thus supported physical activity for overall well-being, including

physical, psychological, and social enhancement as benefits and reasons for sustained

participation. In addition, incorporating physical activity in an outdoor setting was

restorative and enhanced the benefits of solo physical activity. Though helpful in

understanding the benefits of exercise outdoors, including exercising with others, these

studies were not specifically aimed at gaining understanding of walk-and-talk therapy, or

the benefits for individuals psychological distress. As previously mentioned, traditional

therapy has been conducted within the frame of an office to support confidentiality and

set the tone of the therapeutic encounter. The following section addresses traditional talk

therapy and frame.

Traditional Therapy

Therapeutic lifestyle changes such as physical activity are considered beneficial

for physical and mental health, for proactively promoting general well-being, and for

treatment of mental health diagnoses (Howell et al., 2016; Walsh, 2011). Although

clinicians may be familiar with the overall benefits of therapeutic lifestyle changes,

physical activity is often categorized as a treatment for physical health or is considered an

adjunct to talk therapy for mental health (Walsh, 2011). Most therapy continues to occur

in a safe (Duros & Crowley, 2014), enclosed space, free from distraction (Jordan, 2015;

Jordan & Marshall, 2010; Langs, 1979), Though therapeutic approach or treatment

modality might differ among therapists, traditional psychotherapy has remained focused

on talking therapies (Chalquist, 2009), and the efficacy of traditional talk therapy is

supported by research.

Benefits of Therapy

Talk therapy as a treatment for psychological well-being has been well researched

with correlations between psychotherapy and improvements in mental health similar to

treatment with psychotropic medications alone (Hollon & Ponniah, 2010; NIMH, 2018;

Substance Abuse and Mental Health Services Administration [SAMHSA], 2017), or

increased benefit in mental health when therapy was combined with medication (Hollon

& Ponniah, 2010; NIMH, 2018; SAMHSA, 2017). Many specific talk therapy

interventions are regarded evidence-based practices and deemed better for specific mental

disorders, such as mild to moderate depression or anxiety (NIMH, 2018; SAMHSA,

2017). With psychotherapy, individuals may experience the added benefits of

circumventing or managing future psychological symptoms even after therapy has ceased

whereas symptoms could return when medication is discontinued (Hollon & Ponniah,

2010). In addition, some individuals are unable to tolerate specific medications or are

unable to obtain sufficient symptom relief from medication alone (Hollon & Ponniah,

2010). Walk-and-talk therapists reported their outdoor therapy sessions were informed by

the same theories (Jordan, 2014) and treatments they used during indoor sessions (Revell

& McLeod, 2016). Therefore, this literature review focused more specifically on aspects

common to most indoor therapy experiences including the therapeutic frame rather than

treatment modalities.

Frame of Traditional Therapy

Physical setting. In the early stages of psychoanalysis, Freud organized the

physical setting of the therapy room with therapist sitting out of client’s sight to create a

space he believed conducive to his psychoanalytic model (Freud, 1913; Laws, 2009).

During the 1960s, counselors such as Rogers altered the therapeutic space so client and

therapist faced each other to facilitate the empathy and genuineness believed crucial to

the processes of therapy (Laws, 2009; Rogers, 1961). This face-to-face arrangement

remained the standard for therapeutic frame (Laws, 2009) with a few exceptions.

The Freudian couch was revisited to investigate how Jungian therapists have

evolved in their use of chair or couch in the therapy space (Connolly, 2015; Wiener,

2015). A number of prominent therapists’ beliefs were explored regarding whether a

couch for reclining, or a chair for sitting face-to-face was more conducive to the

therapeutic process, specifically when using the psychoanalytic approach (Connolly,

2015). A lack of research existed that demonstrated either couch or chair was better or

preferred by clients or therapists (Connolly, 2015). Having an office setting with a proper

couch that may be used by clients to sit or recline facing toward or away from the

therapist allowed the client to choose what was most comfortable with the option to

change position at any time, and was considered informative to the therapeutic process

(Connolly, 2015). Therapists may have offices containing a chair that clients may chose

if they feel uncertain or unable to participate in the depth of work they believe they must

do if using the couch; however, the office setting reflects the person of the therapist and

their approach to therapy (Connolly, 2015; Wiener, 2015). Although therapists expressed

differences of opinion and practices regarding couch versus chair for specific therapeutic

modalities, therapists reinforced a model with an indoor setting and comfortable furniture

where client had the option to recline or sit and to opt for or against eye contact

(Connolly, 2015; Wiener, 2015). Despite allowing clients these choices, therapists

continued to maintain power in choice of furnishings and arrangement that set the tone

and implied expectations for therapy (Connolly, 2015; Wiener, 2015). This further

reinforced clients’ perception that indoor therapy offices create a space, frame, and power

differential in favor of therapists (Jordan, 2013).

Therapeutic frame. Two prominent voices in the field of psychodynamic therapy

regarding what aspects of the therapeutic frame are secure versus deviant, or necessary

versus flexible are Langs and Casement (Milton, 1993). Langs (1979) considered a

number of items important to create a secure frame of therapy in order that a basic sense

of trust was established between client and therapist, interpersonal boundaries were

clearly articulated and understood, and healthy, balanced therapeutic work focused on the

client’s issues was conducted (Milton, 1993). This secure frame required a private,

soundproof office space; sessions with set time, length, and fee; and set places for client

and therapist with no physical contact occurring between them (Langs, 1979; Milton,

1993). Therapist attention to these fixed, steady aspects of therapy created a secure space

in which client trust of therapist as competent and sane professional was established and

where psychodynamic therapy could be conducted in a fluid and dynamic manner for the

purpose of symptom resolution (Langs, 1979; Milton, 1993). Langs viewed any change in

the frame that altered any secure aspect less than optimal and a threat to the quality of

therapy (Milton, 1993).

Casement (2014; Milton, 1993) agreed with Langs regarding many aspects of

therapeutic frame including a confidential and private meeting space with set

appointment times, and no physical contact; however, Casement indicated a willingness

to consider some flexibility that met client needs (Casement, 2014; Milton, 1993).

Specifically, client should determine what positions client and therapist assumed during

the therapeutic encounter (i.e., face-to-face or some other positioning) and use of the

therapeutic space based on what the client found comfortable and therapeutic (Casement,

2014; Milton, 1993). The frame of walk-and-talk therapy would be considered radically

deviant given an outdoor setting where other individuals might be encountered or might

overhear the content of therapy (Jordan & Marshall, 2010); however, it provides another

option for clients who might not find indoor office spaces therapeutic. Beyond setting the

stage for the work of therapy, the frame of therapy assists therapists in other ethical

obligations to their clients.

Ethical considerations. Mental health clinicians’ professional codes of ethics

help ensure client beneficence and avoidance of maleficence (AAMFT, 2016; APA,

2010). Professional ethics cover a variety of aspects that help establish therapeutic frame

including client confidentiality and safety. In addition, clinicians are expected to be

trustworthy, and to provide interventions backed by research in which they have adequate

training and experience (AAFMT, 2016; APA, 2010; Duros & Crowley, 2014), as well as

providing cost-effective services that meet client needs (Anderson & Brownlie, 2011).

Confidentiality and safety. The types of topics discussed in therapy sessions are

often quite sensitive and likely to evoke strong emotions (McLeod, 2013). An indoor,

enclosed office space ensures these conversations are not overheard, as well as creating a

space in which client and therapist have a measure of safety from outside influences

(Jordan, 2015; McLeod, 2013). In addition, it is important therapists only practice

interventions in which they are sufficiently educated and their licensing boards recognize

(Duros & Crowley, 2014). Beyond a safe, secure meeting space, and the assurance of

confidentiality, researchers declared the importance of the relationship between client and

therapist was key as well.

Therapeutic alliance/relationship. The relationship between therapist and client

is a common factor determined important to the success of therapy outcomes (Laska,

Gurman, & Wampold, 2014; Wampold, 2015). Clients need to be able to trust their

therapist; know the therapist has the necessary qualifications and expertise to manage

their particular issue; and know the therapist is willing to engage in a genuine, empathic

relationship (Wampold, 2015). This relationship creates human connection, or

attachment, important to the success of therapy (Wampold, 2015). Human connection in

the context of psychotherapy creates a supportive environment to explore difficult

circumstances and emotions thus adding to the aspect of safety (Wampold, 2015).

Beyond relationship and support, the therapeutic alliance consists of agreement about the

goals and tasks of therapy (Wampold, 2015). Therapeutic alliance is generally solidified

early in the therapy process—usually by the third or fourth session—and is highly

predictive of outcome (McLeod, 2013; Wampold, 2015). Thus, the frame of therapy

includes a relational component built on trust and agreement regarding goals and tasks of

therapy. Despite efforts of therapists to create a confidential and safe space, as well as a

trusting relationship conducive to therapy, some individuals continue to experience

barriers seeking therapy.

Barriers to Seeking Psychotherapy

Despite benefits and successful therapy outcomes, barriers to seeking

psychological treatment continue to exist. Because of the stigma associated with mental

health, many individuals do not seek help until they have endured tremendous mental,

emotional, or relational distress (Charbonneau, 2016). In addition to this stigma, cost of

treatment prevents people from seeking psychological intervention (Anderson &

Brownlie, 2011). Barriers are often associated with client demographics, such as

socioeconomic status, age, gender, race, or level of education (Anderson & Brownlie,

2011), as well as attitudes about perceived need for treatment, or issues related to cost or

availability of treatment (Andrade et al., 2014). Older people, males, and those with less

education are less likely to seek emotional support thus prompting the question of

whether less formal and less stigmatizing approaches might be more beneficial

(Anderson & Brownlie, 2011). Poorer and lower educated individuals are less likely to

seek out therapy yet most likely to be prescribed medication for psychological issues

(Anderson & Brownlie, 2011) despite evidence that therapy may be as beneficial as

medication with less chance of relapse over time (Hollon & Ponniah, 2010). Furthermore,

not everyone finds the traditional frame therapeutic (Laws, 2009). Cockrell echoed this

with his belief that walk-and-talk therapy was well suited for men because walking side-

by-side avoided the intimate and potentially intimidating face-to-face posturing in

traditional therapy (Wright, 2008).

An ethnographic study was conducted with a group of 23 individuals who

organized their own psychiatric survivor support group upon discharge from a psychiatric

facility in Northern England and themes of therapeutic spaces and places emerged from

their responses (Laws, 2009). Participants purposely chose meeting spaces others deemed

dissident but that aligned with their identity and needs because traditional therapy spaces

and methods were not meaningful or therapeutic for them (Laws, 2009). Participants

viewed therapeutic spaces, places, and methods subjectively, and felt that traditional

spaces and rules regarding session length and processes created an atmosphere where

therapist maintained control (Casement, 2014; Milton, 1993; Jordan, 2014) and power,

and client was passive (Laws, 2009). The members of the survivor group “appropriated”

(Laws, 2009, p. 10) spaces for themselves outside of the norm thus mirroring taking

control of their lives, health, and therapeutic processes. Conversely, for others the

confinement of a walled therapy space was preferred and more therapeutic (Laws, 2009).

Participants demonstrated activism and action in their recovery process through their

appropriation of space and in the manner in which they sought change for themselves and

others (Laws, 2009). These individuals were able to externalize their mental turmoil by

meeting outdoors and maintaining an outward focus (Laws, 2009). This study was

important because the concept of therapeutic can be subjective. Weaknesses of this study

were its inability to be applied or generalized broadly because the participant group was

quite narrowly defined and unique as members either partially or totally rejected

traditional psychotherapy or psychiatric treatment.

Thus there are a myriad of considerations regarding what is therapeutic for clients

and also meets professional ethical standards. Although talk therapy has been one of the

primary treatments for psychological distress, a number of individuals have challenged its

focus on cognitions and insisted that interventions should attend to bodily processes

because psychological distress manifests in the body (Young, 2008). Approaches have

ranged from attending to body language or nonverbal cues in talk therapy or

incorporating physical activity as an adjunct to or within talk therapy, to incorporating

specific movements, dance, or yoga in therapy sessions. The next section addresses

incorporation of the body in psychotherapy.

Physical Activity, the Body, and Therapy

Despite early theorists and practitioners believing in a mind-body connection

(Janet, 1905; Janet, 1906; Young, 2008) and treating individuals with “psychoorganismic

totality” (Brown, 1973, p. 100), psychotherapy in its current form has separated mind and

body and focused mostly on cognitions (Young, 2008) with some focus on interpretation

of body language or nonverbal communication (Watchel, 1967). Freud incorporated

integration of physical aspects into treatment considerations with his early focus on

libido; however, he later focused on unconscious mental states to the exclusion of any

form of physical components in his psychoanalytic treatment modality (Young, 2008).

Reich practiced psychoanalysis with a focus on the interconnectivity of mind and body,

but was expelled from the Psychoanalytical Association in 1934 thereby ushering in the

un-embodied, cognitive approach to psychotherapy (Young, 2008). Nevertheless, Reich

and others continued to champion the interconnectedness of body and mind. A

resurgence of body therapies, including Gestalt, Reichian, Lowenian Bio-energetics, and

Janov’s primal therapy, occurred in America when a new wave of psychologists and

mental health clinicians embraced the “wisdom of the body” (Brown, 1973, p. 98). These

iterations of combining body and mind in psychotherapy continue to exist in therapeutic

practice; however, the approach to the importance of body in therapy has taken different

forms in more recent years.

Physical Activity as an Adjunct to Therapy/Counseling

The benefits of physical activity for overall well-being have been well established

and many providers recommend physical activity for psychological distress; however,

this recommendation is often as an adjunct to psychotherapy or pharmacologic treatments

(Howell et al., 2016; Walsh, 2011) because research supports physical activity as an

adjunct to psychotherapy.

In the 1970s, Kostrubala (1976; 2013) was an early adopter of combining

psychotherapy with outdoor exercise. Having participated in a cardiac rehabilitation

group, Kostrubala (2013) experienced health benefits that he believed would translate

well to his psychiatry practice. Over time, his clients participated in running therapy in

which they ran and walked at their own pace in order to maintain target heart rates for a

designated period of time, after which they participated in a group therapy session

(Kostrubala, 2013). Running therapy correlated not only with physical health benefits,

but also benefits for depression and schizophrenia (Kostrubala, 1976; Kostrubala, 2013).

Similarly, Gontang (2009) and Hays (1994) used running or walking with some of their

clients because of their belief in the added psychological benefits, as did Glasser (1989)

because of his belief in a need for an alternative approach to address the needs of one of

his adolescent female clients.

A feasibility study was conducted to examine whether combining aerobic exercise

as an adjunct to cognitive behavior therapy would be beneficial for posttraumatic stress

disorder (PTSD) for survivors of sexual assault. Results related to improvement in PTSD

symptoms were not measured; however, retention and satisfaction with cognitive

behavior therapy plus exercise was extremely high (Smith, 2015). This finding could be

of importance when examining the combination of talk therapy with exercise outdoors as

retention and satisfaction with therapy may be predictive of better outcomes. These

findings are also important because of the added benefit of exercise with traditional talk

therapy for psychological symptoms. Using physical activity as an adjunct to

psychotherapy, naturally led the abovementioned therapists to incorporate physical

activity into their therapy sessions.

Including Physical Activity in Therapy

A number of therapies exist where clinicians use physical movements, stimuli,

and body-mind approaches to treat specific psychological issues and stress. Mind-body

theories are based on the belief that environmental and psychological stressors create a

physical stress response and by attending to the physical manifestations these effects may

be lessened or reversed (Payne & Crane-Godreau, 2015). Reich believed that individuals

developed somatic symptoms for psychological distress through body armoring and that

therapeutic interventions needed to be physical as well as psychological (Young, 2008).

Increasingly therapists have used body movement such as dance (Burns, 2011), yoga

(Gangadhar & Varambally, 2015), and mindfulness practices (Gu, Strauss, Bond, &

Cavanagh, 2015) to attend to bodily sensations and create self-reflective practices for

relief of mental and emotional distress.

As indicated by media reports, a number of therapists have introduced physical

activity into their therapy sessions in the form of walking or running (Abcarian, 2017;

Chillag, 2017; Knox, 2017; Magner, 2017: Maher, 2017; Maxted, 2017; Neely, 2017:

Packhams, 2015) including introducing walking in support groups (Barton, 2011), yet it

is not an entirely new practice. A number of clinicians have included walking or running

as part of their therapeutic repertoire, with Freud rumored to have walked with his clients

through the streets of Vienna (Jordan & Marshall, 2010; Karp, 2011) prior to settling on

an enclosed office model of therapy.

In the 1960s, Glasser, a psychiatrist, and the creator of Reality Therapy (Glasser,

1989) worked with young, delinquent females in a residential setting at the Ventura

School for Girls in California. Glasser also focused on addictive behaviors, believing in a

principle of “positive addiction” (Kottler & Carlson, p. 57) where individuals could

replace unhealthy behaviors with healthy behaviors. Doubting the lasting effects of talk

therapy alone, Glasser decided to prescribe physical activity in the form of running for

one patient (Kottler & Carlson, 2003). Being a runner who frequently recommended

physical activity as an adjunct to therapy for other patients, Glasser decided to run with

this young woman twice a week while simultaneously conducting their therapy sessions

(Kottler & Carlson, 2003). This young woman experienced success with these running

sessions, and experienced improvements in well-being as she transitioned from

controlling her unhealthy food intake to controlling her physical activity in a healthier

manner (Kottler & Carlson, 2003).

Hays (1994; 1999) also championed physical activity as therapeutic for

psychological issues by itself, as an adjunct to therapy, as well as conducted

simultaneously with talk therapy. Clients experienced cognitive benefits during and after

physical activity, and they were able to use symbolism and metaphor, as well as use

nonverbal communication during sessions where exercise was incorporated (Hays, 1994).

Therapists who engage in physical activity may also serve as example and role model for

clients (Hays, 1999); however, engaging in physical activity alongside clients is not

without potential consequences (Hays, 1994; Hays, 1999). For instance, clients may have

concerns about their level of fitness compared to their therapist or running alongside their

therapist may develop into a competition or power struggle (Hays, 1999). Overall,

however, clients enjoyed synergistic benefits when their therapist joined them in physical

activity as a part of their therapy process including shifting control and responsibility for

outcomes from therapist to client (Hays, 1999). Additionally, therapists were cautioned to

consider the changes in boundaries and power (i.e., frame), as well as issues of

confidentiality when conducting therapy sessions outdoors while engaging in running or

walking (Hays, 1999).

Thus, for quite some time therapists have believed in the benefits of physical

activity for overall well-being, including psychological well-being. Incorporating

physical activity for psychological benefit is not a new phenomenon; however, there are

numerous considerations for therapists opting to include physical activity in therapy

sessions. Duros and Crowley (2014) described how trauma impacts clients’ bodies in

addition to their emotions thus there has often been a need to incorporate alternative

interventions beyond talk therapy; however, in doing so there was also a need to ensure

client safety and comfort. Running or walking has typically been the easiest way in which

to incorporate physical activity into a therapy session (Hays, 1999) with walking being a

much less strenuous activity in which most individuals can engage easily and safely

(Murthy, 2017; HHS, 2015, Vanderbilt, 2012); however, therapists did not begin

incorporating walking in therapy sessions in a more mainstream manner until the early

21st century.

The experiences of the professionals mentioned earlier are important because

these clinicians reported benefits for overall well-being, as well as specific psychological

benefit (Hays, 1994; Hays, 1999; Kostrubala, 1976; Kostrubala, 2013; Kottler & Carlson,

2003); however, other than Hays, these clinicians failed to address issues that may arise

when combining physical activity in a therapy session. In addition, Kostrubala typically

engaged clients in running in a group setting at a track where clients could run at their

own pace with group therapy sessions occurring after their running sessions (Kostrubala,

1976; Kostrubala, 2013). Thus, these clients did not truly experience the phenomenon of

simultaneous physical activity and talk therapy. In addition, these accounts of

incorporating exercise as an adjunct or as part of the therapy session were not from the

clients’ perspectives. Furthermore, because of the location of their sessions, the

participants’ experiences may have differed from clients whose therapist engaged them in

walk-and-talk therapy in a park or forest setting. It is unclear in what setting Glasser

incorporated running therapy with his client suffering with an eating disorder. As

mentioned earlier, the settings in which physical activity occur are a mediating factor

influencing participant experiences with physical activity in more natural settings being

correlated with greater improvements in mood than physical activity in more urban

settings (Bratman et al., 2015; Shanahan et al., 2015). Thus it is important to examine the

importance of nature exposure to well-being.

Nature Exposure

As early as the 1980s, those living in more industrialized nations spent greater

than 90% of their time indoors (Chalquist, 2009). This increased time indoors, in built

environments, particularly in crowded urban settings is often associated with increased

stress and decreased well-being (Chalquist, 2009). Nature exposure has been found to be

a mitigating factor for psychological health as individuals were able to reconnect with

nature (Burns, 2011; Chalquist, 2009). Exposure to outdoor settings, particularly green

spaces, and those located close to water such as a lake or ocean, correlated with

restorative properties (Ulrich, 1979; Jordan, 2015). Shinrin-yoku, or forest bathing, was

also deemed beneficial for physical and psychological health (Li, 2018). Adolescents

participating in wilderness therapy also experienced improvements in psychological

health (Hoag et al., 2016). It is important to consider the healing power of exposure to

natural environments given the increasing trend toward urban living and subsequent

negative health effects (Shanahan et al., 2015). Individuals experiencing emotional stress

exacerbated by urban environments might benefit from nature exposure resulting in

emotional and physical health improvements (Stigsdotter et al., 2011). Similar to

traditional talk therapy and physical activity, there is evidence supporting nature exposure

for psychological and overall well-being, as well as in combination with either talk

therapy or physical activity.

Benefits of Nature Exposure

The benefits of nature exposure have been studied extensively from a variety of

perspectives ranging from viewing natural settings (Ulrich, 1979; Ulrich, 1984) and

incorporating natural elements into indoor environments (Gessler, 1992) to immersive

experiences in nature (Hoag et al., 2016; Li, 2018). Ulrich (1979; 1984) examined the

effects of nature exposure on physical and psychological health. Individuals recovering

from surgery had a quicker recovery and better relationship with hospital staff when they

recovered in a room with a window view of a more natural setting (Ulrich, 1984). In

addition, individuals who viewed natural versus urban landscapes reported higher

subjective psychological well-being (Ulrich, 1979). Differences exist between passive

versus active interaction with natural versus built settings as well .

In a study in which 60 participants were randomly assigned to two groups,

participants who walked in more natural settings versus urban setting had greater

affective and cognitive benefits (Bratman et al., 2015). The contribution of nature

exposure to better cognition and affect may be explained by stress reduction theory and

attention restoration theory; however, further examination of different types of natural

environments and different lengths of time spent in them, as well as assessment of affect

and cognition at various times during the walks as opposed to only at the conclusion of

the walks was recommended (Bratman et al., 2015). In this study psychological

differences between walking in urban versus natural settings were highlighted the effects

of walking were controlled, thus reinforcing the therapeutic benefit of nature, allowing

for further examination of the talk therapy component, and highlighting a need for further

study of the influence of different environments and lengths of time spent walking.

The influence of exercise versus rest indoors and outdoors were compared

through an experimental study and findings of increased positive affect and energy

through exercise and nature exposure were discovered (Fuegen & Breitenbecher, 2018);

however, in contrast to Bratman et al. (2015), no significant improvement in attention

was reported as a result of exercise or nature exposure (Fuegen & Breitenbecher, 2018).

Activity conducted either indoors or outdoors was found better than no activity for a

boost in energy (Fuegen & Breitenbecher, 2018). Improvements in affect occurred with

either activity indoors or outdoors, or resting outdoors, with greatest gains in positive

affect from exercise outdoors (Fuegen & Breitenbecher, 2018). Thus, therapists working

with individuals with mood disorders may want to consider incorporating physical

activity and nature exposure during, or as an adjunct to therapy sessions.

In a randomized control trial comparing nature-based therapy to a cognitive

behavioral approach for stress management, nature-based therapy was associated with

similar results in improvement in mental and physical health symptoms at the conclusion

of the intervention, but also a year post intervention (Corazon et al., 2018). In addition,

participants in both treatment groups experienced long-term reductions in healthcare

utilization thus further supporting the efficacy of nature-based therapies for psychological

and physical well-being (Corazon et al., 2018), a finding likely of importance to policy

makers, healthcare organization leaders, and insurance payers.

In another pilot study investigating the correlation between mental well-being,

depressive symptoms, and restorative benefits from a treatment intervention including

nature walks at alternating treatment sessions, participants experienced increases in

mental well-being and decreases in depression over the course of the eight-week

intervention continuing through the 3-month follow-up (Korpela et al., 2016). In addition,

the nature walks versus the indoor treatment experiences appeared to mediate the

increases in positive mental well-being from baseline through follow-up (Korpela et al.,

2016). This study was significant because of its focus on individuals with a diagnosis of

depression because most research on the relationship between nature exposure and well-

being has been done with the general population (Korpela et al., 2016).

Although research has supported ties between exposure to nature and overall

well-being including physical health benefits and subjective overall well-being, there was

need for further study of how much of a dose (i.e, frequency and duration of exposure) of

nature was required to obtain and/or sustain health benefits (Shanahan et al., 2015). This

was important in light of urbanization and increased proportions of the population living

within urban environments with less nature or green spaces (Shanahan et al., 2015).

Moderating factors that could influence dose included culture, socioeconomic

status/advantage, personal preferences, and/or demographics (Shanahan et al., 2015).

This is of interest because of the connection between health and nature, as well as the

importance of measuring how often or for how long people need to experience nature

before they experience benefit. Although individuals exercising alone or in natural

settings may experience gains, and individuals experiencing nature exposure alone may

also experience benefit to well-being, it would be important to know how much clients

benefit from a single, weekly, 45-minute walk-and-talk therapy session.

These studies demonstrated evidence that nature exposure was beneficial for

overall well-being, including a decrease in depressive symptoms for those carrying a

diagnosis of depression (Korpela et al., 2016) and nature-based therapy should be

formatted to meet client needs (Stigsdotter et al., 2011). Thus, a variety of nature-based

therapies exist that have paved the way for walk-and-talk therapy, including ecotherapy,

nature therapy, horticulture therapy, animal-assisted therapy, adventure, and wilderness

therapy.

Types of Nature-Based Therapies

The field of nature or outdoor therapy has expanded in recent years. Ecotherapy,

or the application of ecopsychology, is a broad term referring to numerous treatment

approaches involving nature exposure or activities incorporating interaction with nature

to enhance psychological well-being (Chalquist, 2009; McLeod, 2013). Various

modalities include, but are not limited to, nature therapy (Berger & McLeod, 2006),

horticulture therapy (Soderback, Soderstrom, & Schalander, 2004), animal-assisted

therapy (Kamioka et al., 2014; Maujean, Pepping, & Kendall, 2015), and wilderness or

adventure therapy (Chalquist, 2009; McLeod, 2013). Clinicians frequently use wilderness

and adventure therapy with younger populations, whereas older populations might find

less intense ecotherapy interventions such as gardening or nature-based walking groups

more appealing. Though the manner varies in which therapists conduct nature-based

therapies and interventions, as do the amount of focus therapists direct toward interaction

with nature, these therapies have the common elements of a natural setting, greenspace,

or incorporation of natural components (Stigsdotter et al., 2011). Therapists who conduct

nature-based therapies often do so out of personal belief in the benefits of nature

exposure for well-being (Jordan, 2014).

Walk-and-talk therapy is another emerging type of nature-based therapy where

therapists often conduct their therapy sessions outdoors in a more natural setting;

however, in walk-and-talk therapy the outdoor, natural setting is more often a backdrop

rather than an active component of the therapy session. Walk-and-talk therapists have,

however, eluded to their belief in the restorative power of the nature component of walk-

and-talk therapy (Jordan, 2015; King, 2015; McKinney, 2011). Walk-and-talk therapy

will be discussed further in a separate, dedicated section.

Ecotherapy. Ecotherapy was defined as treatments that incorporate elements of

nature toward growth and healing (Chalquist, 2009). Although there are a variety of

ecotherapy modalities ranging from incorporating natural pictures or fragrances, to

hands-on interaction such as gardening, ecotherapists promote connection between

humans and the natural world (Jordan, 2015; McLeod, 2013). Previous studies on

ecotherapy linked increased psychological symptoms with disconnection from nature and

improvement in these symptoms with reconnection with nature (Chalquist, 2009). This

was an important consideration for this study as I examined how walk-and-talk therapy

might influence clients’ perceptions of connection/reconnection with nature that might

thus inform their experience of therapy or their psychological symptoms.

Nature therapy. Nature therapy is therapy conducted in an outdoor space

wherein nature is not merely a backdrop to the therapy process but a “partner in the

process” (Berger & McLeod, 2006, p. 80). Participants viewed nature as a living and

dynamic partner, yet neutral and not under the control of the therapist; therefore, it

allowed clients to take more ownership of the therapeutic frame and processes (Berger &

McLeod, 2006). Nature therapy might involve a single client and therapist, or multiple

clients and therapist or group leader.

Horticulture therapy. Horticulture therapy ranged from participants viewing

natural spaces, such as gardens, to sitting or walking in gardens (McCaffrey & Liehr,

2016), to actual hands-on gardening (Soderback et al., 2004). People of all ages and

abilities found it useful, and it may be done in a variety of settings from inpatient,

outpatient, community, and independent home settings (McCaffrey & Liehr, 2016;

Soderback et al., 2004). Participants reported improved affect, relaxation, and

improvements in overall well-being, as well as increases in self-esteem (Soderback et al.,

2004) and reductions in psychological stress (McCaffrey & Liehr, 2016). The

improvements experienced by participants reflected the benefits of interaction with

nature; however, walk-and-talk therapists use nature as backdrop rather than an entity

with which participants actively engage through gardening or landscaping.

Wilderness and adventure therapy. Wilderness and adventure therapies have in

common components of challenge and overcoming circumstances in outdoor settings

(Gelkopf, Hasson-Ohayon, Bikman, & Kravetz, 2013; McLeod, 2013). Adventure

therapists often incorporate man-made obstacles in addition to natural ones, whereas

wilderness therapists mainly incorporate overcoming natural obstacles or challenges such

as weather or navigating a difficult terrain (McLeod, 2013). Participants are challenged in

how they relate to others as wilderness and adventure therapy frequently require working

with others (Bettmann, & Jasperson, 2008; Gelkopf et al., 2013; McLeod, 2013). In

wilderness programs, participants are typically separated from their daily routines and

interactions in order to establish healthier attachment (Bettman & Jasperson, 2008), and

improvement in mental well-being (Hoag et al., 2016). Critics of wilderness therapy

suggested that some of the interventions could be easily adapted to indoor or urban

settings and were not dependent upon a nature-based setting (Rutko & Gillespie, 2013).

Those opposed to traditional therapy, including combat veterans with PTSD, may find

adventure therapy a suitable alternative (Gelkopf et al., 2013). Participants reported

relationships with other participants as mediating treatment factors in adventure and

wildnerness therapy (Gelkopf et al., 2013; Bettman & Jasperson, 2008). Although the

intensity of these types of therapies far exceed walk-and-talk therapy, including the level

of interaction with nature, participant experiences with these therapies inform the frame

of nature-based therapy, particularly with regard to how participants relate to the outdoor

environment, as well as the relational components of these therapies.

Animal-assisted therapy. Animal-assisted therapy is another possible nature-

based therapy (McLeod, 2013), although animal-assisted therapy also involves care for a

pet indoors or at home (Maujean et al., 2015). Therapy incorporating animals may also be

divided into animal-assisted therapy where an animal is used to assist in achieving a

specific goal; versus animal-assisted activities, such as caring for animals in order to

bring about improvement in well-being (Maujean et al., 2015; Kamioka et al., 2014).

Although some walk-and-talk therapists may allow clients to bring their pets along for

sessions, walk-and-talk therapy generally does not incorporate animal-assisted therapy or

animal assisted activities.

The aforementioned nature-based therapies have in common an altered frame of

therapy, particularly those involving immersion in natural environments. Thus it was

important to consider this altered frame and clients’ perspectives of it.

Frame of Nature Therapy

When therapists take therapy outdoors into a garden, greenspace, nearby park, or

rural setting, they remove the rigid office boundaries and alter the frame of therapy

(Jordan, 2015). As also previously mentioned, some therapists believe nature may shape

outdoor therapy in a dynamic way as participants interact or connect with their

surroundings (Berger & McLeod, 2006; Chalquist, 2009; Jordan & Marshall, 2010), or as

participants engage with their therapist or other clients in a new way (McLeod, 2013;

Adams & Morgan, 2018). In addition, outdoor settings, especially more public or rural

ones, are no longer under the control of the therapist and may create a new therapist-

client power differential (Jordan & Marshall, 2010; McLeod, 2013). Researchers have

discovered additional processes in nature-based therapies that also have bearing on

therapeutic frame.

Over the period of three years, individuals participated in a nature-based program

for psychological distress (Adams & Morgan, 2018). Participants attended eight-week

seasonal sessions that involved various group activities in an outdoor setting in southern

England. Believing that a solid evidence base was already established regarding the

benefits of nature exposure for well-being, the authors sought to understand the added

psychosocial dynamic of social interaction during these outdoor interventions (Adams &

Morgan, 2018). Study participants described themes of escape, being present, social

contact, and personal growth related to the outdoor setting and social interaction (Adams

& Morgan, 2018). Participants described escape from their everyday circumstances and

settings, and their own internal processes, as well as into a setting that provided a safe

backdrop conducive to being present in the moment and with others (Adams & Morgan,

2018). Individuals reported social contact was correlated with the benefit of immediate

social connection, as well as laying a foundation for future social interactions (Adams &

Morgan, 2018). Finally, participants described ways in which the natural setting and

social interaction created opportunities for personal growth through self-reflection

leading to self-acceptance, and a focus on an optimistic future (Adams & Morgan, 2018).

Participant responses mirrored recovery processes posited by Leamy (2011) of

connectedness, future orientation, empowerment, identity, and meaning of life (Adams &

Morgan, 2018). It is therefore important to consider the overlap of setting and social

interaction for psychological and general well-being (Adams & Morgan, 2018). Although

not specifically examining walk-and-talk therapy, this study was important because it

highlighted the overlap of contextual and relational factors, described the clients’

perspectives and noted that some participants found the outdoor, natural environment a

safe space (Adams & Morgan, 2018).

Inpatients being treated for significant mental illness (i.e., depression, bipolar, or

anxiety disorders) were recruited to participate in a mixed methods study to determine

what participants found beneficial regarding group forest walks (Iwata et al., 2016).

Patients participated in the group forest walks as an adjunct to their treatment as usual

and no other therapeutic intervention was imparted during the walks; rather, participants

were free to walk or talk with other participants (Iwata et al., 2016). Participants

demonstrated significant short-term improvement in positive affect and reduction in

negative affect, as well as longer-term sustained benefits (Iwata et al., 2016). Participants

indicated that being in a quiet setting away from others contributed to a peaceful and

calming effect, and some indicated the change of setting to a more beautiful and

interesting context was helpful (Iwata et al., 2016).

In these nature-based group therapy interventions the frame of therapy differed

from that of indoor therapy not only through the difference in setting, but also in terms of

how participants engaged in the therapeutic process and with one another. Participants in

these studies reported a safe, calm environment that was conducive to improvements in

well-being. Similar to incorporating physical activity into therapy, mediating factors

existed for nature-based therapies as well.

Mediating Factors of Nature-Based Therapy

A number of studies have been conducted to explore the phenomena of nature

exposure and well-being, and included a combination of a physical activity or a social

component or both. Individuals with significant mental illness who participated in a

group forest-walking program experienced short-term increased positive affect and

decreased negative affect (Iwata et al., 2016). In addition, longer-term outcomes for some

participants included medication reduction, fewer hospitalizations over the course of the

program, with one participant able to return to work (Iwata et al., 2016). Participants

reported the social interaction, as well as the nature exposure, were impactful in these

outcomes and the role of regular physical activity could not be ignored (Iwata et al.,

2016).

Participants in a mixed-methods study investigating perspectives of primarily

outdoor group therapy experiences reported helpful aspects that included being outside,

connection with nature, ability to reflect, and interaction with others (Revell, Duncan, &

Cooper, 2014). Participants further reported the majority of interpersonal benefits were

with other participants rather than the therapist. The perceived benefits of the

combination of therapy in an outdoor setting was from the perspective of the participant;

however, walk-and-talk therapy was not specifically addressed as an outdoor therapy.

More specifically, in the aforementioned studies, a one-to-one client-therapist

relationship was not examined (Iwata et al., 2016; Revell et al., 2014) thus revealing

another gap in the knowledge base.

Thus far in the literature reviewed, positive associations existed between talk

therapy for overall well-being, as well as for physical activity and nature exposure. In

addition, physical activity as an adjunct or in combination with talk therapy was found

beneficial for well-being, as were a number of nature therapies. Participants cited social

interaction in the form of the client-therapist relationship, as well as connection with

others and with nature, as important factors for participating in exercise and nature

therapies, as well as reasons to continue participation. Walk-and-talk therapy is a

combination of aspects related to physical activity, nature exposure, and social

interaction, and the next section includes research specific to the practice of walk-and-

talk therapy.

Walk-and-Talk Therapy

A number of therapists have incorporated walk-and-talk therapy in its current

form through the years. This may be inferred as Freud was rumored to have walked with

his clients (Jordan & Marshall, 2010; Karp, 2011), and as other therapists throughout the

20th century experimented with running and walking with their clients (Glasser, 1989;

Hays, 1994; Kostrubala, 1976; Kostrubala, 2013; Pullen, 2017). Its mainstream use,

however, appears to be a more recent development with increasing media exposure.

Media coverage of the practice has blossomed during the early 21st century as a new

approach to treating psychological issues and stress (Abcarian, 2017; Chillag, 2017;

Knox, 2017; Magner, 2017: Maher, 2017; Maxted, 2017; Neely, 2017: Packhams, 2015).

Although the practice has been described as taking “ordinary counselling” (McLeod,

2013; p. 350) into an outdoor setting, clinicians and researchers familiar with the practice

expressed the importance of considering the change in the frame of therapy and

experience that occurs for therapists and clients when taking it into open, outdoor, public

spaces (Jordan & Marshall, 2010; McLeod, 2013). Despite concerns over this change in

frame, those therapists who have embraced the practice believe it to be an intuitive

treatment.

Early Adopters

As mentioned previously, Kostrubala (1976), Glasser (1989), and Hays (1994)

were pioneers in combining outdoor physical activity in the form of running or walking

with clients with an ordinary therapy session. In addition to the influence of these

clinicians, the advent of the current iteration of walk-and-talk therapy in the United States

appears to stem from the example of Clay Cockrell, a New York social worker who

began offering walk-and-talk sessions to his busy clients in 2004, and received a great

deal of media attention ranging from Good Morning America to The Wall Street Journal

(Charbonneau, 2016; Cockrell, 2013). A number of therapists interviewed in subsequent

media coverage cited Cockrell as their inspiration (Chillag, 2017; Maher, 2017; Neely,

2017). Similarly, William Pullen (2017), a psychotherapist in the United Kingdom who

practices Integrative Psychotherapy and founded Dynamic Running Therapy, has been

the inspiration for other walk-and-talk or running therapists (Maxted, 2017; Packhams,

2015) in the United States and the United Kingdom.

Current Practice

Some walk-and-talk therapists, such as Cockrell, conduct their sessions in urban

parks (Chillag, 2017; Cockrell, 2013), while other therapists choose more secluded or

rural settings such as hiking trails (English, 2015; Neely, 2017) or beaches (Revell &

McLeod, 2016). Some therapists abide by a traditional therapy hour whereas others opt

for longer sessions depending on setting, client issues, or client or therapist preference

(Blue Cloud Walking, n.d.; English, 2015). Some offer initial sessions indoors (Chillag,

2017; English, 2015) as well as bring sessions indoors for inclement weather or if the

client expresses a desire to be inside because of the sensitivity of the session’s content

(Chillag, 2017; Cockrell, 2013). Most incorporate the same treatment modalities they use

in traditional indoor, office therapy sessions (Revell & McLeod, 2016) and the cost of

sessions are roughly the same as office sessions (Cockrell, 2013). The main difference in

walk-and-talk therapy is the format where client and therapist walk side-by-side outdoors

in a natural setting.

Therapists’ Perspective of Practice

In a mixed-methods study of therapists’ perspectives of what they found helpful

or hindering aspects of walk-and-talk therapy, participants reported that walk-and-talk

therapy was more casual, collaborative, and facilitated a better therapeutic alliance

(Revell & McLeod, 2016). Therapists also believed walk-and-talk therapy helped clients

who were feeling stuck move forward in their journey more quickly (Revell & McLeod,

2016). On the other hand, therapists reported concerns with weather and maintaining

proper boundaries in therapy, as well as struggling to attend to therapeutic content and

process while walking outdoors (Revell & McLeod, 2016). Further research from the

clients’ perspectives, as well as further research to help create standard practices for those

clinicians engaging in walk-and-talk therapy practice were recommended (Revell &

McLeod, 2016). This aligned with others’ caution against assuming any particular setting

holds therapeutic value, as well as encouragement to explore individuals’ subjective

perspective of what they deem intrinsically therapeutic (Bell et al., 2018; Houghton &

Houghton, 2015).

In a doctoral study on therapists’ perceptions of walk-and-talk therapy 11 walk-

and-talk therapists were interviewed to generate a theory and framework of walk-and-talk

therapy based on Glaser’s six Cs (McKinney, 2011). The context of therapy was our

overall society in which younger therapists are more open to using alternative therapy

interventions and methods and therapists abided by the conditions that therapy

interventions arose out of client needs, based on contingencies of the therapists’ personal

experiences, the example set by other therapists, and the need for other options, including

their desire to get out of the office (McKinney, 2011). The causes that led to the

development of walk-and-talk therapy included changing client needs coupled with

covariance of research supporting an increasingly inactive society that was also

experiencing a deficit of nature exposure (McKinney, 2011). Through the example of

Cockrell the practice was born resulting in consequences of benefits to clients and

therapists alike with some limitations specific to the outdoor, walking framework

including confidentiality, and challenges and speed in building therapeutic relationship,

among others (McKinney, 2011). No special training was identified to conduct walk-and-

talk therapy beyond minimal requirements for clinical licensure and a walking path

outdoors, and traditional therapeutic interventions were the norm among walk-and-talk

therapists (McKinney, 2011). Practitioners described limitations of walk-and-talk therapy

including lack of support among other clinicians and leaders, difficulty obtaining clients,

and the perception that some client populations were better suited to walk-and-talk

therapy than others (i.e., individuals, and those with less severe symptoms; McKinney,

2011). Limitations to the logistics of walk-and-talk therapy included weather,

confidentiality, and safety (McKinney, 2011). In addition, walk-and-talk therapists

reported difficult conceptualizing therapy, meaning it was more difficult attending to

client issues and remaining present with the client versus in-office sessions (McKinney,

2011).

The contribution of this research was important as McKinney (2011) explored the

evolution of walk-and-talk therapy, including the influence of Cockrell in shaping the

practice, and other walk-and-talk therapists’ experiences and thoughts. Emergent themes

from participant interviews touched on aspects of therapeutic frame from the therapists’

perspectives as well, including confidentiality, safety, and therapeutic alliance

(McKinney, 2011). These same walk-and-talk therapists believed the practice beneficial

to therapist and client alike indicating the casualness of the practice may be appealing to

clients; however, lacking was the clients’ perspectives of the practice, specifically the

altered frame of being outdoors in nature, walking side-by-side versus sitting face-to-face

in an office space (McKinney, 2011). Finally, therapist participants in this study were

self-selected volunteers and likely had a positive view of the practice as they were among

some of the early adopters largely based on their personal beliefs in the benefits of

physical activity and nature exposure (McKinney, 2011). In light of these findings and

limitations, further research was recommended to inform perceptions across the field of

mental health and to inform training, supervision, and practice, as well as to determine

clients’ perceptions of walk-and-talk therapy (McKinney, 2011).

Another immersive, narrative, doctoral dissertation inquiry of four practitioners

allowed for rich description of the lived experiences of other walk-and-talk therapists

through shared stories (Charbonneau, 2016). This study was conducted, “(a) to explore

the psychological understanding of place, (b) to question the idea that therapy needs to be

conducted only in small rooms indoors, (c) to present experience that highlighted the

benefits of going outside, and (d) to evoke the challenges and therapeutic outcomes of

[walk-and-talk therapy]” (Charbonneau, 2016, p. 61).

Four narrative threads emerged from conversations with four walk-and-talk

therapists: social complexities, connecting to a greater sense of the world, acknowledging

the therapist, and innovation and creativity (Charbonneau, 2016). Therapists mentioned

complexities that arose during the course of taking therapy outside that included issues of

confidentiality, emotional regulation for the client (i.e., what happens if they become

emotional or cry in public), and issues of standard of care and ethical practices

(Charbonneau, 2016). Therapists reported that clients were far less worried about these

issues than therapists, and the therapists began walk-and-talk therapy with informed

consent (Charbonneau, 2016). In addition, therapists agreed that walk-and-talk may not

be appropriate for every client, but it was an option for those for whom it felt like a good

fit (Charbonneau, 2016). According to these four therapists, conducting walk-and-talk

sessions outdoors also provided a space that was not controlled or owned by the therapist,

but rather co-navigated by therapist and client creating a collaborative relationship

(Charbonneau, 2016). In addition, therapists related the ways in which they were able to

incorporate nature and the unpredictability of navigating public spaces into therapy

content (Charbonneau, 2016). Therapists also reported the practice of walk-and-talk

therapy was a good fit for their subjective identities as they enjoyed physical activity and

nature (Charbonneau, 2016). All four believed they received personal benefit from

conducting outdoor walking sessions; however, they warned about the need for therapist

self-care outside of these sessions and that therapy sessions were to focus on the clients

(Charbonneau, 2016). The therapists embraced innovation and creativity and felt that

these were to be valued in approaching therapy of any sort (Charbonneau, 2016). They

agreed that walk-and-talk therapy could be viewed as a specialty niche more appropriate

for some clients than others, but that this provided variety and options for clients and may

reduce some of the stigma associated with seeking therapy (Charbonneau, 2016). Finally,

there was agreement that walk-and-talk therapy was simple and could be conceptualized

as normal therapy outside; however, there was also belief that there was more to it as

clients and therapists navigated dynamic, ever-changing environments together, and there

was a shared belief that further research was important (Charbonneau, 2016). The need

for clients’ perspectives of the practice was also highlighted confirming one of the

current gaps in the literature (Charbonneau, 2016).

Additional studies were conducted examining aspects of working with clients

outdoors (Harris, 2014; King, 2015). Four therapists who practice outdoors were

interviewed as part of an IPA study to discover how working with clients outdoors might

influence the therapeutic relationship (Harris, 2014). The role of nature in outdoor

therapy sessions ranged from backdrop to dynamic third participant, and therapists

described the ways in which they alternated between being active facilitator of the

therapeutic process within a natural setting, to being a more passive “witness, container,

and mediator” (Berger & McLeod, 2006, as cited by Harris, 2014, p. 15). Three themes

emerged from interviews with four therapists with different backgrounds and theoretical

approaches: the process, indoors/outdoors, and culture; however, it was difficult to

determine agreement of what constitutes therapeutic relationship through the literature

review, and the variation in treatment approaches and interventions conducted by this

study’s participants did not add any clarity (Harris, 2014). The choice of interpretive

phenomenological analysis, however, was appropriate as Harris sought to understand

what his therapist participants believed about the therapeutic relationship in the context of

outdoor therapy. Because this study was yet another from the perspective of outdoor

therapists, it was not appropriate for further understanding of clients’ perspectives thus

further exposing the gap in the knowledge base. In addition, it was not specific to walk-

and-talk therapy.

Another phenomenological study focused on the shared lived experiences of

outdoor therapists and findings mirrored those later discovered by Charbonneau (2016),

including concerns with training, supervision, and ethics; therapists’ beliefs about the

benefits to clients, including connection with nature; and the therapists’ collaborative role

(King, 2015). Additionally, therapists believed there was a spiritual component to

conducting therapy outdoors (King, 2015). A strength of this study was the

phenomenological approach to gain depth of understanding of the lived experience of the

therapists, however, this study was also from the perspective of the therapists conducting

the outdoor therapy rather than clients, and it was not specific to walk-and-talk therapy.

Wessan (2018) published a case study describing one of her client’s experiences

with walk-and-talk therapy. This client suffered from complex trauma and her therapeutic

progress had slowed (Wessan, 2018). Upon engaging in walk-and-talk therapy the client

experienced a break-through described as “astonishing” (Wessan, 2018, p. 17), and was

able to move past one particularly crippling traumatic experience. Wessan (2018)

hypothesized the mind-body connection experienced through walk-and-talk allowed her

client to access this trauma in a new way, process, and release it. This case study is useful

for beginning to understand potential benefits of adding physical activity in a natural

environment to traditional psychotherapy modalities (i.e., dialectical behavior therapy);

however, it is also from the perspective of the therapist rather than the client.

Prior to his untimely death (Marshall & Hinds, 2017), Martin Jordan (2013, 2015;

Jordan & Marshall, 2010) was an emerging expert on the European equivalent of walk-

and-talk therapy. Jordan’s focused his work on the therapists’ perspective of the frame of

outdoor therapy and his work will be discussed in the section on frame of walk-and-talk

therapy.

Clients’ Perspective of Practice

Although researchers have been studying walk-and-talk therapy more during the

early 21st century, the research has been largely from the perspective of the therapists. I

was only able to locate a single study framed from the perspective of walk-and-talk

therapy clients. In a phenomenological study in which adolescents participated in

outdoor, walk-and-talk therapy sessions, the benefit of these sessions were evaluated by

the adolescents, the counselor/researcher, parents, and teachers (Doucette, 2004).

Although positive results were reported, including “solutions to problems” (Doucette,

2004, p. 386), the exercise and outdoor components of the walk-and-talk intervention

were more peripheral to the therapeutic approach (e.g., solution focused) and

incorporation of attachment theory (Doucette, 2004). Though the walk-and-talk therapy

intervention was introduced from the participating adolescents’ perspectives (Doucette,

2004), there was room for further, objective study from adult walk-and-talk therapy

perspectives particularly regarding adult walk-and-talk therapy participants’ beliefs about

the shift in therapeutic frame.

Frame of Walk-and-Talk Therapy

Walk-and-talk therapy in may range from walking/hiking to camping expeditions

(Jordan & Marshall, 2010). Through specific case examples, challenges and opportunities

of outdoor therapy experiences were explored including having to redefine the frame and

boundaries of therapy and the therapeutic spaces, but also addressing clients’ issues in a

more fluid and emergent manner (Jordan & Marshall, 2010). Some of the risks of outdoor

therapy sessions included the need to address confidentiality when the physical

boundaries of a walled office are no longer present (Chalquist, 2009; Jordan & Marshall,

2010), and when outdoor spaces became therapy and social spaces (Jordan & Marshall,

2010). Issues of geography and power that are not normally of concern within traditional,

indoor therapy sessions were highlighted (Jordan & Marshall, 2010). Therapists’ and

clients’ perspectives of the outdoor therapy experience were explored, though clients’

experiences were reported by the therapist participants.

Subsequently, Jordan (2013) later conducted a narrative doctoral study on the

practice of outdoor therapy, with focus on the frame of therapy, again from the therapists’

perspectives. Themes of confidentiality and client safety surfaced yet again, as well as

potential boundary issues, and the distractions that naturally occur in outdoor or public

spaces (Jordan, 2013). Therapists must work hard to maintain the frame of therapy in

outdoor settings, but it is possible with flexibility and with client understanding (Jordan,

2013). When therapy was taken outside of an enclosed office the therapist became the

holder of the therapeutic frame meaning the therapist had to be comfortable with

maintaining appropriate, yet fluid boundaries (Jordan, 2013). Similar to other findings,

therapists believed outdoor therapy results in an equal distribution of power in the session

and more collaboration (Jordan, 2013). Finally, therapists believed outdoor therapy was

more multidimensional and allowed for a more holistic approach to well-being (Jordan,

2013). The recommendation to inquire of outdoor therapy clients for their perspectives of

outdoor, or walk-and-talk therapy practices was made yet again (Jordan, 2013).

Literature Analysis

As evidenced by the literature reviewed thus far, talk therapy was well established

as an efficacious treatment for psychological distress (i.e., stress, depression, or anxiety),

either alone or in combination with psychotropic medication (Hollon & Ponniah, 2010;

NIMH, 2018; SAMHSA, 2017). Physical activity as a therapeutic lifestyle change, as an

adjunct to traditional talk therapy or in conjunction with therapy, was also found

beneficial for mental well-being (Blair et al., 2012; Febbraio, 2017; Reiner et al., 2013;

Rot et al., 2009). Evidence gathered from this literature review also supported the

efficacy of nature exposure for overall well-being, as a standalone intervention (Bratman

et al., 2015; Feugen & Breitenbecher, 2018; Korpela et al., 2016); in conjunction with

therapy in the form of ecotherapy, horticulture therapy (McLeod, 2013; Soderback et al.,

2004), forest bathing (Li, 2018), or other forms of nature-based therapy interventions

(Gelkopf et al., 2013; Jordan, 2015; Tucker et al., 2016); or in combination with physical

activity (Bratman et al., 2015). Finally, relationships, including the relationship between

client and therapist highlighted as a common factor influencing therapy outcomes, were

deemed important factors contributing to well-being (Laska et al., 2014; Wampold,

2015). Walk-and-talk therapy exists at the intersection of these components.

There is a need to attend to client comfort and safety in therapy (Duros &

Crowley, 2014; Jordan, 2015) as well as to provide a space conducive to therapeutic

gains (Langs, 1979; Laws, 2009) that is appropriate for the client’s presenting issue

(Duros & Crowley, 2014). Attention must also be given to whether the therapy setting is

therapeutic to individuals participating in therapy (Adams & Morgan, 2018; Houghton &

Houghton, 2015; Laws, 2009). Therapeutic interventions should also be supported by

scholarly research and therapists should be adequately trained in any intervention they

deliver (AAMFT, 2016; APA, 2010; Duros & Crowley, 2014).

Although natural outdoor settings are viewed as therapeutic landscapes (Gesler,

1992; Laws, 2009) that contribute to improvements in mood and well-being (Chalquist,

2009; Stigsdotter et al., 2011), individuals may find different settings more therapeutic

depending on accessibility, perceived safety, or level of activity or stimulation (Grant et

al., 2017; Laws, 2009). Though critics of outdoor, nature-based therapies, such as walk-

and-talk therapy, cited concerns over client confidentiality and safety (Charbonneau,

2016; Jordan, 2015; Wright, 2008), some participants in outdoor therapy programs felt

outdoor spaces were safe and relaxing (Adams & Morgan, 2018; Iwata et al., 2016).

Nontraditional outdoor spaces were more comfortable for some individuals than

traditional, inpatient or office settings, thus there is a need to attend to the influence of

spaces and places in therapy (Laws, 2009) in addition to therapeutic treatment modality.

Although research exists on walk-and-talk and outdoor therapy from the

therapists’ perspective (Charbonneau, 2016; Jordan, 2013; King, 2015; McKinney, 2011;

Revell & McLeod, 2016), I was unable to find research of walk-and-talk therapy from the

clients’ perspectives aside from a single, older study about adolescent clients’

experiences (Doucette, 2004), and anecdotal information from therapists’ points of view

regarding their clients’ experiences. Although the current literature on walk-and-talk

therapy from the therapists’ perspectives was informed by input from these same

therapists’ clients (Jordan, 2015), I identified the lack of research specific to the clients’

perspective of walk-and-talk therapy as a gap in the current knowledge base.

Furthermore, therapists conducting therapy in outdoor settings believed the frame and/or

boundaries of outdoor therapy are different than in-office therapy and thus may alter the

experience of therapy for walk-and-talk clinicians and clients alike (Jordan & Marshall,

2010; Jordan, 2015). This creates unique challenges (Jordan, 2015), and may alter the

experience of the processes and some aspects of therapy, such as confidentiality,

potentially creating ethical issues (Hooley, 2016). Although therapists’ perspectives of

what they deem helpful or hindrances of walk-and-talk therapy and why they believed it a

beneficial, therapeutic alternative to traditional office talk therapy were presented (Revell

et al., 2014), little was known of what clients found helpful or hindering regarding walk-

and-talk therapy. Thus, I investigated clients’ perspectives of walk-and-talk therapy and

the subsequent change in traditional therapeutic frame through a qualitative,

phenomenological study.

Summary

Through this literature review, I documented the supporting literature for the

components that make up the practice of walk-and-talk therapy. I presented the existing

literature specific to walk-and-talk therapy, including limitations and recommendations

for future research. Finally, I established a noteworthy gap in the knowledge base

supporting the importance of this study. In Chapter 3 I describe the chosen research

methodology for this research study focused on walk-and-talk clients’ perspective of the

altered frame of walk-and-talk therapy.

Chapter 3: Research Method

Introduction

Because of the lack of research regarding walk-and-talk therapy despite its

expanding use, it was important to gain a better understanding of the practice, especially

from clients’ perspectives because research has been largely from the therapists’

perspectives (Charbonneau, 2014; Jordan & Marshall, 2010; King, 2015; McKinney,

2011). Thus, I conducted a qualitative study for the purpose of gaining a better

understanding of adult clients’ lived experience of walk-and-talk therapy. I chose a

phenomenological approach to understand walk-and-talk therapy clients’ lived

experience (Merriam & Tisdell, 2016; Moustakas, 1994) of the altered frame of walk-

and-talk therapy where therapy sessions occur outdoors while client and therapist walk

side-by-side.

In this chapter, I present the research design and why it was appropriate for

studying the phenomenon of interest. I further outline the role of the researcher and

provide a detailed description of the specific methodology including participant selection

criteria and protocol, data collection, and analysis. Finally, I address issues of

trustworthiness, including validity and reliability, and ethical considerations.

Research Design and Rationale

Research Question

How do adult clients experience talk therapy conducted while walking side-by-

side with their therapist in an outdoor setting?

Research Tradition

The research tradition I chose for this study was a qualitative, phenomenological

approach. Qualitative inquiry is designed to gain an in-depth understanding of a

phenomenon, event, or process, or the lived experience of individuals (Moustakas, 1994;

Smith et al., 2009). This study was conducted to understand adult clients’ lived

experience of the practice of walk-and-talk therapy. Because walk-and-talk therapy is a

fairly new approach to psychotherapy, and the research that I was able to locate was

limited to therapists’ perspectives, I determined that a qualitative approach was

appropriate for gaining a better understanding of adult clients’ experience of the frame of

walk-and-talk therapy (Maxwell, 2005; Moustakas, 1994; Patton, 2015). A

phenomenological inquiry allowed for in-depth exploration of clients’ experiences,

including the context of the outdoor setting coupled with physical activity and the shift

from sitting face-to-face to walking side-by-side.

The type of qualitative inquiry that I chose was the IPA approach, which is

informed by three philosophic traditions: phenomenology, hermeneutics, and idiography

(Smith et al., 2009). As a phenomenological and hermeneutic approach, IPA researchers

focus on the meaning and sense individuals make out of their experiences, particularly

because they are unique to the individuals (Smith et al., 2009). In addition, IPA

researchers employ an idiographic approach with focus on the particular (Smith et al.,

2009). Small, homogenous samples allow for detailed data collection and systematic

depth of analysis to create a greater understanding of a specific phenomenon (Smith et

al., 2009).

IPA is useful for gaining an understanding of participants’ perceptions of their

lived experiences while also seeking to understand how they make sense of these

perceptions (Brocki & Wearden, 2006). Because therapists use the frame of therapy to

lay the foundation for the work of therapy, a change in context, setting, and boundaries

may create a different experience for therapy clients (Jordan & Marshall, 2010; Jordan,

2015). IPA can also be useful for exploring an overall phenomenon through recollection

of parts of the experience and the meaning individuals assign to each (Smith et al., 2009).

In this manner, IPA helped to understand how former walk-and-talk clients make

meaning of the parts (i.e., talk therapy, physical activity, nature exposure, and shift from

sitting face-to-face to a side-by-side arrangement) as they relate to the overall experience,

encompassing the components of the biopsychosocial conceptual framework that also

informed this study. Thus, an IPA approach allowed for examination of the significance

of this altered frame through the lens of the clients’ perception of their lived experience

of participating in walk-and-talk therapy (Smith et al., 2009) and how they make sense of

the altered frame (Brocki & Wearden, 2006).

I considered other qualitative research methodologies for this study; however, I

chose IPA as a phenomenological design that was the most appropriate because my focus

was understanding the essence of the participants’ lived experience of a unique

phenomenon (Moustakas, 1994) through a small, homogenous sample (Smith et al.,

2009). I did not choose grounded theory because it is intended for developing nomothetic

theory that may be later tested and more generally applied to a population (Merriam &

Tisdell, 2016; Sofaer, 1999), and my focus was on a specific phenomenon that may not

extend beyond the experiences of participants. Additionally, I did not choose case study

methodology because it involves multiple data points (Maxwell, 2005; Merriam &

Tisdell, 2016; Yin, 2014) and does not focus on the meaning making or essence of the

participants’ experience of a phenomenon (Moustakas, 1994). I also did not consider

ethnography as an appropriate methodology because of its focus on understanding and

describing a shared culture through immersion in and observation of it over time (Lincoln

& Guba, 1985; Maxwell, 2005; Merriam & Tisdell, 2016). The focus of this study was on

understanding how the clients made sense of their experience of the frame of therapy

rather than the overall culture of walk-and-talk therapy. Finally, narrative inquiry is

focused on understanding and communicating an individual’s unique story (Maxwell,

2005; Merriam & Tisdell, 2016), but IPA still allowed me to present the stories of how

participants make sense of their experiences informed by the narrative tradition and

supported by participant utterances (Bruner, 1991; Smith et al., 2009). As a

phenomenological approach, IPA incorporates aspects of some of the other qualitative

traditions, with a focus on understanding the underlying essence and how participants

make meaning of a phenomenon, making it suited to this study.

Role of Researcher

In qualitative inquiry, the researcher serves as primary instrument of data

collection (Merriam & Tisdell, 2016). In IPA inquiry, the researcher also embodies a dual

hermeneutic role in inquiry and analysis (Smith et al., 2009). First, the researcher acts as

the interviewer (Smith et al., 2009), attending to and documenting participants’

descriptions of their experience while these participants are attempting to make sense of

and communicate their experience. Second, the researcher attempts to understand and

interpret the meaning the participants are communicating about their experiences,

facilitating responses while interpreting them (Smith et al., 2009). Thus, my role in this

study was as interviewer for data collection and interpreter for data analysis. I did not

serve as either observer or participant, as I interviewed former walk-and-talk clients of

other therapists rather than my own clients. I also did not observe actual walk-and-talk

therapy sessions with current clients. Both of these stipulations acted as safeguards to

avoid ethical concerns of confidentiality and power differentials between therapist and

client (AAMFT, 2016; APA, 2010).

In any qualitative inquiry it is important to address potential researcher bias—

both known and unknown (Moustakas, 1994). As a walk-and-talk therapist, I brought

known personal bias into this study that I managed by acknowledging it through

reflexivity, and controlling for it through epoche (Moustakas, 1994). Epoche involves

suspending judgment by examining personal beliefs regarding the phenomenon of

interest followed by setting aside, or bracketing, any prior assumptions to focus on the

essence of what is being communicated by study participants (Merriam & Tisdell, 2016).

Further, data collection and analysis should be approached with doubt of prior knowledge

in favor of seeking new knowledge (Moutsakas, 1994). From the outset of this study, I

acknowledged and documented my preconceived understanding of clients’ experiences of

walk-and-talk therapy based on my own experiences as a walk-and-talk therapist. I also

set aside these assumptions in order to be present with the participants, the data, and the

essence what the participants communicated regarding their experiences. Furthermore, I

employed the technique of free imaginative variation, a form of eidetic reduction,

wherein I attempted to imagine different possibilities or explanations for the essence of

walk-and-talk therapy participants’ experiences (Smith et al., 2009).

Despite my efforts to bracket experiences, attempts to completely bracket

preconceptions are not possible, and sometimes knowledge of bias arises through the

analytical process (Smith et al., 2009). As I noticed my personal biases surface, I further

managed these through acknowledging and documenting them through journaling,

followed by bracketing and focusing on the subjective experiences detailed by the study

participants. Finally, it was important to acknowledge limitations to the study that arose

out of the inability to remove my prior understanding in this IPA study and to allow for

the possibility that there could be other interpretations (Smith et al., 2009).

Methodology

Participant Selection Logic

Qualitative study participation is different from quantitative study participation in

that data collection often involves intense interaction resulting in rich, descriptive, written

data (Merriam & Tisdell, 2016). For this reason, qualitative researchers often employ the

use of in-depth, semistructured interviews for phenomenological inquiry (Merriam &

Tisdell, 2016; Moustakas, 1994; Smith et al., 2009). Interviews are more personal,

intense interactions providing detailed and descriptive data, and thus recruitment

procedures for qualitative inquiry must be specific while planning for participant safety

and anonymity (Smith et al., 2009).

Population. Although qualitative study results are not generalizable to a

population because of the nature of qualitative research, including small sample sizes

(Moustakas, 1994; Patton, 2015; Smith et al., 2009), it is still important to identify the

population from which participants will be recruited and are thus representative. The

population that was represented by this study was adult walk-and-talk therapy clients.

Sampling strategy. Through IPA inquiry, researchers use purposeful,

convenience sampling to obtain a small and homogenous sample for providing detail and

depth (Smith et al., 2009). Frequently participants are recruited by referral or through

snowball sampling (Smith et al., 2009). Although walk-and-talk therapy is gaining in

popularity, the number of walk-and-talk therapy clients is still a small percentage of

therapy clients in general. Thus, to reach former walk-and-talk therapy clients, referrals

for participants were obtained from walk-and-talk therapists who acted as gatekeepers to

accessing these individuals. Walk-and-talk therapists identified via Internet searches and

social media such as Facebook, Instagram, Twitter, or LinkedIn were contacted via e-

mail and asked to forward study information to their former walk-and-talk therapy

clients. Snowball sampling (Merriam & Tisdell, 2016; Smith et al., 2009) was also used

by asking walk-and-talk therapists as well other therapists and colleagues to forward to

me the information for other walk-and-talk therapists they may know or to forward study

information to other individuals they may know that may have also participated in walk-

and-talk therapy sessions.

Participant selection criteria. Therapy clients are considered a more vulnerable

population and involving them in research created potential ethical issues (AAMFT,

2016; APA, 2010; Walden, 2015). Walden’s Institutional Review Board (IRB) allows for

recruiting individuals who have completed treatment for phenomenological analysis of

their past experience, but I also took precautions to ensure participant safety of former

walk-and-talk therapy clients (Walden, 2015). Other precautions included having

voluntary participation, not involving participants where I held any authority or

maintained any level of familiarity with them, and distinguishing the study as research

and not a therapeutic intervention (Walden, 2015). I did not recruit any of my own past or

present therapy clients, thus avoiding familiarity or undue influence. Additionally, only

adults over the age of 18 were eligible to participate.

To promote ethical recruitment and treatment of study participants, I implemented

a screening protocol. First, all potential participants were adult volunteers recruited

primarily per invitation forwarded by e-mail from their former therapist. Participants also

responded affirmatively to recruitment protocol and contacted me voluntarily. I further

screened these volunteers for study suitability, including a review of inclusion criteria.

Protocol required treating potential or actual study participants in immediate danger of

harm to self or others as any other individual in crisis, and attempts, to keep this

individual safe were planned per researcher’s professional licensure protocol (AAMFT,

2016). This was not an issue and no crisis interventions were necessary. Upon

verification that the individuals met inclusion criteria and receipt of their signed consent,

participant interviews were scheduled.

Number of participants. By their nature, qualitative, phenomenological studies

are designed to use small sample sizes because of the desire to obtain quality, detailed,

rich, descriptive accounts of lived experiences (Moustakas, 1994; Smith et al., 2009). IPA

researchers similarly use small sample sizes ranging from as small as a single case (Smith

et al., 2009). Though single case IPA studies have become more popular as the method

has gained popularity, single cases are usually saved for distinct cases likely to have a

powerful impact on the phenomenon of interest (Smith et al., 2009). The minimum

recommendation was for a range of three to six cases to provide meaningful

representation without creating an undue burden of an overwhelming amount of data

(Smith et al., 2009). A small number of cases also allows for a homogenous sample, a

hallmark of IPA (Smith et al., 2009). Given these considerations, as well as the potential

difficulty I might have encountered when attempting to recruit participants who met the

criteria, I planned to recruit a minimum of four participants. I understood that I might

need to recruit more as the study progressed to reach data saturation (Merriam & Tisdell,

2016; Patton, 2015). However, despite recruiting efforts, I was only able to recruit three

study participants. Explanation of recruitment efforts and subsequent difficulties are

outlined in the next section and in Chapter 4.

Recruitment procedures. Recruiting therapy clients was challenging for a

number of reasons. Although walk-and-talk therapy is being more widely practiced, it is

still not standard practice, and locating walk-and-talk therapy clients through more

traditional recruiting methods such as advertisements would have been difficult.

Therefore, I chose to locate walk-and-talk therapists first for the intention of purposeful

and convenience sampling. Therapists who agreed to pass along information were not

asked to target specific former clients but were asked to pass along information to all

former clients to avoid identifying study participants. I also asked whether these

therapists knew of other walk-and-talk therapists who might also be willing to pass along

the opportunity to their clients in a snowball-sampling manner. When recruitment

protocol was not sufficient to recruit the minimum number of participants, I attempted a

broader dissemination of study information by forwarding study information to

colleagues and other mental health professional organizations, including the Metro-

Atlanta Therapists Network, as general mental health practitioners may have former

clients who have also participated in walk-and-talk therapy sessions. Potential former

walk-and-talk client participants who did respond were screened for suitability for

participation in the study as previously described, including being mentally and

emotionally stable enough to participate in research to avoid maleficence (AAMFT,

2016; APA, 2010).

Saturation. Saturation occurs when similar patterns develop during data analysis

and there is minimal likelihood that any new insights will be gained from any additional

data collection (Fusch & Ness, 2015; Merriam & Tisdell, 2016). It was important to have

a sufficient sample size for replication and saturation as well as to provide information

that supported the observed phenomenon (Merriam & Tisdell, 2016). Adding further

cases over time if replication or saturation did not occur with the initial sample size was

recommended (Merriam & Tisdell, 2016; Smith et al., 2009). As described, I began with

the intent of recruiting a minimum sample of four participants, resulting in a minimum of

four interviews while allowing for recruitment of additional participants over time until

saturation was apparent and the likelihood that additional significant insights would not

occur with the addition of more cases. However, I was only able to recruit three

participants, which will be addressed again as a limitation in Chapter 5.

Instrumentation

Semistructured interviews. Data collection was through in-depth, semistructured

interviews that “invite[d] participants to offer a rich, detailed, first-person account of their

experiences” (Smith et al., 2009, p. 56). Through in-depth interviews, participants could

more fully convey their thoughts and feelings regarding their experience of the

phenomenon of interest (Smith et al., 2009). IPA interviews are typically approached as a

purposeful conversation guided by the research question (Smith et al., 2009). I composed

interview questions in open-ended fashion, and designed them to allow participants to

respond with as much detail or description as they felt comfortable (Smith et al., 2009).

Additional, open-ended questions were included as prompts to encourage participants to

reflect on and describe their experience of the various biopsychosocial components of

walk-and-talk therapy individually and together. The semistructured interview schedule

may be found in Appendix A.

The following interview questions were proposed for conducting a semistructured

interview to answer the overarching research question, “How do adult clients experience

talk therapy conducted while walking side-by-side with their therapist in an outdoor

setting?”

1. How did you decide to participate in walk-and-talk therapy instead of

traditional in-office therapy?

This question was posed to gain an understanding of whether clients self-selected to

participate in walk-and-talk therapy or whether it was at their therapists’ recommendation

as this could influence a client’s experience of their therapy (Jordan & Marshall, 2010;

Langs, 1979; Laws, 2009). In addition, this question was posed to begin building rapport

and facilitate the interview process (Smith et al., 2009).

2. Tell me what it was like for you to participate in therapy sessions outdoors

while walking with your therapist.

Per IPA interview protocol, this was an open-ended, non-leading question aimed at

gaining an understanding of participants’ experience of the phenomenon (Smith et al.,

2009). In addition, this question contained elements that addressed the biopsychosocial

components contained in the conceptual framework that shapes the frame of therapy, and

are the lenses through which this study was approached.

The following prompts were used as needed, and to elicit more detailed

information about the participants’ experience of the biopsychosocial components that

shape the phenomenon of walk-and-talk therapy:

• How did being outdoors influence your experience of your therapy sessions?

• How did walking influence your experience of your therapy sessions?

• In walk-and-talk therapy you are side-by-side with your therapist rather than

face-to-face. How did that influence your experience of your therapy

sessions?

• Tell me more about _______________.

This prompt was used as needed to elicit more detailed information regarding any

prior question or any unanticipated information participants divulged that may have been

useful in understanding their experience of the frame of therapy, particularly as it related

to the whole as well as its parts (Smith et al., 2009).

• What else do you think it is important for me to know about your experience

of walk-and-talk therapy?

This question allowed for the participants to relay any additional information they

felt was important about their experiences of the phenomenon of walk-and-talk therapy

that I did not explicitly ask. In addition, I asked this question during member checking to

elicit additional feedback and insights that might have arisen as participants reviewed

their transcripts (Merriam & Tisdell, 2016; Moustakas, 1994). Finally, this question

helped balance researcher bias (Smith et al., 2009). Participants were allowed to raise

additional insights that challenged researcher’s personal experience and bias as a walk-

and-talk therapist.

Audio recordings. Qualitative researchers frequently use audio recordings of

interviews and transcribe them to reference for accuracy and to use in the data analysis

process (Merriam & Tisdell, 2016). IPA inquiry specifically calls for verbatim

transcription of any interactions (Smith et al., 2009). By recording and transcribing

interviews I was able to keep data organized and facilitate data analysis (Smith et al.,

2009). Interviews were conducted via Internet video chat, and recordings were made

through the Zoom video-conference platform. In addition, backup audio recordings were

made using a digital hand-held recorder and a Livescribe smart pen. Listening and re-

listening to the recordings, as well as using the transcriptions during the analysis process

allowed for additional opportunities for new insight (Smith et al., 2009).

Procedures for Recruitment, Participation, and Data Collection

Walk-and-talk therapists’ e-mail. I began recruiting participants by contacting

walk-and-talk therapists. I located these therapists via Internet search and social media

platforms as well as through my professional affiliations. I contacted these therapists by

e-mail explaining the study and asking that they forward information to their former

walk-and-talk therapy clients within a week. In snowball sampling fashion, I asked these

same therapists to forward information for other therapists they may know who might

also be willing to forward study information to their former walk-and-talk therapy clients.

Former walk-and-talk clients’ e-mail invitation. Former walk-and-talk therapy

clients who received the e-mail invitation forwarded from their therapists were asked to

contact me via e-mail within seven days. I responded to potential study participants’ e-

mails of interest within 24 hours and scheduled a brief phone call to review study criteria

and informed consent. If the volunteer remained interested, the informed consent was e-

mailed. Once a participant returned the signed informed consent their interview was

scheduled

Had more than the minimum of four participants responded with interest and met

screening qualifications, I would have added these extra participants to a waiting list for

future interviews should additional cases be needed to accomplish saturation; however, as

previously mentioned, I only recruited three participants. Because recruitment lagged

behind the minimum four, I continued to contact additional walk-and-talk therapists;

however, despite my efforts and follow through, I exhausted my resources and settled for

three interviews.

Interviews. I conducted interviews by Zoom video-conference platform. I

scheduled these interviews for two hours to allow plenty of time for thick, rich

description of the phenomenon; however, each interview lasted slightly less than one

hour. I audio recorded the interviews using a combination of the video-conference

recording feature, a handheld digital recorder, and a Livescribe smartpen as described

earlier as well as kept written notes. I debriefed participants at the end of the interview.

and reminded them I would send a follow-up e-mail with a summary of their responses

for verification through member-checking.

Data Analysis Plan

As previously described, I collected data through semistructured interviews

conducted by me and audio recorded. I conducted these interviews to gain an

understanding of how former walk-and-talk therapy clients experienced and made

meaning of the altered frame of their therapy and to answer the following overarching

research question: How do adult clients experience talk therapy conducted while walking

side-by-side with their therapist in an outdoor setting? I transcribed the interviews and

manually coded and analyzed the data.

In IPA, as in general qualitative inquiry, there is no absolute perfect formula for

qualitative data analysis (Patton, 2015; Smith et al., 2009). During the data analysis

process, however, it was important to focus on how participants tried to make sense of

their experiences (Smith et al., 2009). One manner of attending to participant sense-

making was by incorporating the seven-step, modified van Kaam phenomenological data

analysis methodology aimed at helping participants with feeling understood (Moustakas,

1994; Polkinghorne, 1989).

Starting with the first interview transcript, I began with horizontalization and

listed “every expression relevant to the experience” (Moustakas, 1994, p. 120) detailed

through participant utterances. Next, through reduction and elimination I examined these

utterances to determine whether they were necessary for understanding the phenomenon

and could be abstracted and labeled (Moustakas, 1994). I eliminated participant

statements that did not meet these two requirements as well as overlapping or redundant

statements and the remaining statements were considered the invariant constituents

(Moustakas, 1994). Third, I grouped these invariant constituents according to theme via

clustering and thematizing (Moustakas, 1994). During the fourth step I validated that the

remaining invariant constituents and themes aligned with the overall transcript by either

being explicitly addressed or compatible. Remaining invariant constituents that did not

align at this stage were subsequently deleted. During the last three steps I composed an

individual textural description of the phenomenon, followed by an individual structural

description, and concluded with an individual textural-structural description. I followed

these steps with each subsequent interview. Finally, I composed a composite textural-

structural description of the phenomenon yielding a thick, rich description of the clients’

lived experiences of the phenomenon of walk-and-talk therapy.

Unique to IPA is the manner in which cases are carefully analyzed one at a time

before moving onto the next (Smith et al., 2009). The van Kaam data analysis

methodology aligned with the IPA approach. Once I completed a detailed analysis of the

first case, I repeated the same processes for subsequent cases, considering each as stand-

alone entities (Smith et al., 2009); however, because of the hermeneutic nature of IPA,

prior cases are likely to influence subsequent analysis (Smith et al, 2009). For this reason,

it was important I was mindful of this tendency while being open to new emerging

themes. After I analyzed cases individually, it was possible to conduct a cross-case

analysis to determine similarities and differences (Smith et al., 2009). Finally, I

conducted a deeper micro-analysis to tease out levels of interpretation for the purpose of

comparing, then contrasting these various interpretations (Smith et al., 2009).

Issues of Trustworthiness

Although trustworthiness and study rigor may be judged in various ways to ensure

the qualitative study quality, one set of criteria included credibility, dependability,

transferability, and confirmability (Lincoln & Guba, 1985; Merriam & Tisdell, 2016).

Qualitative researchers must be proactive and address these criteria throughout the

process of data collection and analysis (Merriam & Tisdell, 2016). It is important to

match techniques for trustworthiness to the potential threats that might arise out of the

specific type of qualitative study conducted (Maxwell, 2005). Thus, I address how I

approached trustworthiness for this IPA study in the following sections.

Credibility

Credibility, also known as internal validity in qualitative studies, refers to whether

the findings and interpretations are truly reflective of the phenomenon being studied

(Merriam & Tisdell, 2016; Moustakas, 1994). Credibility may be established in a variety

of ways, including prolonged contact, triangulation, member checks, saturation, and

reflexivity (Moustakas, 1994; Peat, Rodriguez, & Smith, 2019). I used in-depth,

semistructured interviews of a small, homogenous sample size to create prolonged

contact that resulted in a rich and descriptive data set (Smith et al., 2009). I created

additional opportunity for prolonged contact by following up with participants through e-

mail for clarification of their interviews. Triangulation is the use of multiple and diverse

sources of data collection (Maxwell, 2005; Merriam & Tisdell, 2016). Although IPA uses

a small, homogenous sample, I accomplished triangulation through member checking

(Merriam & Tisdell, 2016) and second tier triangulation by comparing analysis results

with professional knowledge and extant literature (Smith et al., 2009). After initial data

analysis, I contacted participants to review their accounts (Moustakas, 1994) of their

experiences in a process called member-checking (Merriam & Tisdell, 2016). This

process also helped to reveal any unchecked personal bias (Merriam & Tisdell, 2016;

Moustakas, 1994) while assessing whether the researcher’s attempts to understand the

participants’ attempts to make meaning of their experience was accurate (Smith et al.,

2009). Saturation also helps establish credibility and involves collecting a sufficient

amount of data that the likelihood of discovering any new information or themes is

doubtful despite adding any more cases or interviews (Merriam & Tisdell, 2016). My

initial intent was to recruit additional participants as needed to meet the criteria of

saturation; however, I was unable to recruit the desired minimum participants and thus

this was a limitation of this study.

I also needed to avoid formulating conclusions too early and remained mindful of

alternative explanations to what I interpreted (Moustakas, 1994). This was of particular

importance as researcher because I am also a therapist who practices walk-and-talk

therapy. For this reason, it was important that I exercised reflexivity (Merriam & Tisdell,

2016; Moustakas, 1994) by tending to how my own bias and the data collection and

analysis processes may have influenced my interpretation of the data (Smith et al., 2009).

Exercising epoche early by bracketing known bias, as well as practicing imaginative

variation by attempting to see things from several angles (Moustakas, 1994), also added

to credibility. Therapists and clients frequently view their experiences of therapy

differently (Timulak, 2010). Thus, interview questions were open-ended and non-leading,

to allow clients many opportunities to articulate their specific perspectives that might

have differed from mine as a walk-and-talk therapist (see Miles et al., 2014; Patton, 2015;

Smith et al., 2009). Attending to differences that surfaced between client accounts was as

important as attending to similarities for the purpose of credibility.

Transferability

Transferability, or external validity, is the ability to generalize findings of the

study to other situations or populations (Merriam & Tisdell, 2016). Qualitative inquiry

does not lend itself to external generalizability; however, qualitative inquiry may serve as

a launching point for theory development (Reid et al., 2005; Smith et al., 2009). Because

of the small, homogenous sample sizes used in IPA inquiry, generalizations to the larger

population may not be made; however, IPA may support theoretical transferability

through rich analysis making connections between detailed participant accounts, the

researcher’s own personal and professional experience, and the existing literature (Smith

et al., 2009) through second tier triangulation of resources and theories (Leung, 2015).

Thus transferability is a limitation of IPA that must be acknowledged, but it may be

increased through contextualizing the experiences of participants so that application may

be made to other similar populations (Merriam & Tisdell, 2016; Smith et al., 2009).

Dependability

In qualitative research, the concept of reliability is often referred to as

dependability. Dependability is the degree to which a research study may be replicated

(Merriam & Tisdell, 2016). In qualitative inquiry, dependability can be a difficult to

promote. To increase dependability it was important to use triangulation and include an

audit trail. As mentioned previously, triangulation allows the researcher to confirm that

the data analysis and interpretation were representative of the participants’ true

experience (Leung, 2015), or their attempts to make sense of their experience

(Moustakas, 1994; Smith et al., 2009). Researchers use audit trails as a detailed roadmap

regarding the research process and methodology from inception to conclusion (Merriam

& Tisdell; 2016). Replication of a study does not imply that the same results will be

obtained as there could be multiple ways to interpret data (Merriam & Tisdell, 2016).

This does not mean a study is not valuable or trustworthy; rather, it is important the

results and interpretations are consistent with participant accounts (Merriam & Tisdell,

2016) and reflect the essence (Moustakas, 1994) and meaning (Smith et al., 2009)

participants attempted to convey.

Because I interviewed multiple participants regarding the same phenomenon, it

was important to document methods and procedures and follow them accurately across

individual interviews (Merriam & Tisdell, 2016; Smith et al., 2009). One way I promoted

dependability was to record and transcribe interactions and have participants verify these

transcripts before data analysis began through member checking (Merriam & Tisdell,

2016; Moustakas, 1994) to make sure I captured the essence of what the study

participants were attempting to communicate (Merriam & Tisdell, 2016; Moustakas,

1994).

Confirmability

Confirmability is comparable to the quantitative imperative of objectivity.

Researchers should strive for objectivity; however, it is not possible to conduct research

in a sterile environment apart from personal bias. For this reason, to control for bias to

increase confirmability of study results, I exercised reflexivity through acknowledging

and bracketing known bias at the outset (Maxwell, 2005; Smith et al., 2009). In addition,

as I conducted data collection and analysis, I maintained a position of curiosity and

allowed for alternate explanations beyond my personal bias (Merriam & Tisdell, 2016;

Moustakas, 1994; Smith et al., 2009). Finally, in hermeneutic fashion that informs IPA, I

was mindful that each step of the data collection and data analysis process had the

potential to influence interpretation. A continued attention toward potential bias and

watching for evidence of unknown biases as they surfaced was important (Smith et al.,

2009). I bolstered confirmability by journaling throughout the process of data collection

and analysis.

Ethical Procedures

The manner in which researchers recruit participants, manage the interview

process, and handle data analysis may bring about numerous ethical considerations

(Merriam & Tisdell, 2016). I addressed some of these issues previously in this chapter

and will also review these in the following sections, as well as address some additional

ethical concerns.

When participants are recruited from vulnerable populations, a number of ethical

considerations may arise. Although not all therapy participants qualify for mental health

diagnoses, research participants who have previously attended therapy are treated with

more caution. Recruiting individuals who have engaged in therapy was not forbidden by

Walden IRB (Walden, 2015), but a number of precautions were recommended, such as

recruiting former clients who have completed treatment to interview them about their past

experience. Having a licensed clinician conduct interviews was also cited as important to

ensure participant comfort and safety (Cooper & McLeod, 2015). Brief screening

interviews with potential study participants to assess suitability for participation and

counseling clients’ comfort with the study were recommended as well (Chandler,

Fernando, Barrio Minton, & Portrie-Bethke, 2015). As a licensed marriage and family

therapist with over 10 years of experience, I believe I was qualified to screen for client

suitability and/or suspend study participation should I deem the process potentially

harmful to the participant. Combining my own clinical judgment with brief screening

helped ensure ethical client participant recruitment.

Throughout study recruitment, I reminded participants that their identity would be

protected, and during a process of informed consent, I notified participants of the

measures that would be enacted to protect their identity, including de-identification and

use of pseudonyms rather than their actual names. I took additional measures to ensure

participant safety, including identifying crisis resources, should any urgent situation arise

during the course of data collection that might require immediate attention or therapeutic

intervention. During informed consent, I followed Walden IRB guidelines (Walden,

2015), detailing the nature of the study, and informing interviewees that their

participation was for research purposes only and the interview would not be a therapeutic

interaction or intervention. An added precaution of the Walden IRB (2015) was ensuring

researchers possessed the appropriate qualifications for working with vulnerable

populations. I detailed these qualifications and other information regarding ethical

management of participant recruitment earlier in the methodology section.

When involving other agencies or institutions, institutional permissions are often

required including letters of cooperation and IRB approval from the other organization.

According to Walden IRB guidelines, however, a letter of cooperation was not necessary

for this study because the therapists who were contacted had no other role than

forwarding information to their former walk-and-talk clients and former client

participation was voluntary and unknown to these therapists (Walden, 2015).

I addressed ethical concerns related to recruitment materials and processes in the

prior sections outlining recruitment. Forwarding the study invitation was voluntary as

was participation. I included a copy of the informed consent with the therapist e-mail, as

well as my contact information should there have been any questions about the study. I

also outlined processes to secure assistance for anyone deemed in acute emotional

distress at any point in the process. Participants were able to withdraw from the study at

any time. If a participant had withdrawn I would have implemented the debriefing

protocol; however, this was not a cause for concern.

Data storage and handling included de-identifying data through coded file names

and pseudonyms. I stored files on a secure, password protected laptop or encrypted hard

drive only accessible to me and stored in a locked file cabinet in my home office. After

dissertation completion, I will maintain the data on the encrypted hard drive for a period

of 5 years, at which time I will reformat the hard drive and erase the data.

I did not involve any of my clients in this study, nor anyone in my work

environment. The walk-and-talk therapists I contacted were unknown to me prior to the

study outside of minimal professional interaction via social media. There was no undue

influence or pressure by me towards the therapists or participants and I attended to the

researcher-participant power differential through respectful acknowledgement throughout

that the participant was the experiential expert (Smith et al., 2009). No incentive was

provided to participants. I sought and obtained approval from Walden’s IRB with

approval number 09-27-18-0383087 and an expiration of September 26, 2019.

Summary

In this chapter I addressed the chosen research methodology and related protocols.

For the purpose of this study, I chose a qualitative, IPA approach well suited to

understanding the essence of clients’ lived experiences of the altered frame of walk-and-

talk therapy sessions. I recruited three former walk-and-talk therapy clients and

interviewed them using a semistructured, in-depth interview protocol. The primary

recruitment approach was e-mails forwarded to former clients by their walk-and-talk

therapists. I conducted coding and data analysis manually. Data collection and analysis

were done from a combined IPA approach attending to my own interpretation of

participants’ meaning-making of their lived experience of walk-and-talk therapy using

the seven-step modified van Kaam phenomenological data analysis approach, while also

addressing issues of trustworthiness through practices such as epoche, triangulation, and

member-checking. In Chapter 4 I will address study results gathered and analyzed

through the proposed IPA methodology.

Chapter 4: Results

Introduction

This IPA study was conducted to better understand clients’ lived experience of

walk-and-talk therapy. In traditional therapy, sessions occur in an enclosed office space

for a confidential and safe therapeutic encounter (Jordan & Marshall, 2010; Langs, 1979),

both to meet clinicians’ ethical requirements to do no harm and to promote therapeutic

benefits for clients (AAMFT, 2016; APA, 2010). Taking therapy sessions outside in an

open, more natural space, and incorporating physical activity by walking side-by-side

creates a different therapeutic encounter and alters the therapeutic frame (Jordan &

Marshall, 2010). Despite recent studies on therapists’ perspectives of walk-and-talk

therapy (Charbonneau, 2016; Jordan, 2013; Jordan & Marshall, 2010; King, 2015;

McKinney, 2011; Revell & McLeod, 2016, 2017), not much is known about clients’

perspectives of the practice. Thus, I conducted this phenomenological study to address

the following research question: How do adult clients experience talk therapy conducted

while walking side-by-side with their therapist in an outdoor setting?

In this chapter, I describe the setting of the study, and the demographics of study

participants. I also outline the data collection and data analysis processes as well as

address trustworthiness based on criteria of credibility, transferability, dependability, and

confirmability, as proposed in Chapter 3. I also delineate any adjustments that arose

during data collection and analysis and conclude with a summary of my study findings.

Setting

Participants were recruited through protocol outlined in Chapter 3, beginning with

identifying walk-and-talk therapists in the United States through Internet searches

(Google and social media). I then e-mailed these therapists and asked them to forward

study information, in the form of a participant invitation e-mail, to their former adult

walk-and-talk therapy clients. These former clients had the option to self-select to

participate in a semistructured interview via online video conferencing using the Zoom

video-conference platform.

I was able to identify 135 therapists across the United States whose websites or

social media accounts indicated that they offered walk-and-talk therapy. Despite multiple

e-mails and phone calls, 56 responded indicating they were unable or unwilling to

forward, and 50 of the therapists never responded to any attempts to contact them. A total

of 29 therapists agreed to forward my study information to their former clients and from

those forwarded e-mail invitations, four participants volunteered and e-mailed me

indicating their interest to participate; however, only three consented and participated in

the interview process, and the fourth did not respond to multiple follow-up e-mails asking

for appropriate times for a brief phone conversation to discuss the study and consent

form.

I had originally intended participants would have terminated their participation in

walk-and-talk therapy within the last 6 months; however, the first volunteer’s past

therapy experience was outside of this 6-month window. In addition, after speaking with

some of the therapists who were willing to forward study information, it became apparent

that this 6-month window was too limited. Thus, I sought and received an IRB

amendment to expand inclusion criteria to include any former walk-and-talk therapy

client regardless of how far in the past their sessions occurred.

I outlined that I was asking therapists to forward the study information to all their

former clients. I did this to broaden the pool of participants, to avoid the perception of

coercion, and to lessen the chance of participants being identified in the final study

description. Despite these efforts, therapist responses suggested that they possibly hand-

chose former clients they felt would be a good fit for this study and believed would likely

respond. These limitations will be discussed further in Chapter 5.

Demographics

Three participants voluntarily self-selected to participate in this study. Per study

protocol, participants were adults over age 18, had previously participated in a minimum

of three walk-and-talk therapy sessions, and were no longer actively participating in any

form of psychotherapy. Finally, participants said that they felt no emotional distress that

would place them at risk of harm to self or others at the time of their participation, and

they provided consent to participate. Participants were females, ranged in age from early

20s to early 50s, and had engaged in traditional, in-office therapy before participating in

walk-and-talk therapy. Two of the three indicated having in-office sessions interspersed

with their walk-and-talk sessions, whereas the third reported that once she began walk-

and-talk therapy she never returned to office-based therapy. Participants described walk-

and-talk settings that included natural elements (i.e., grass, trees, water) and ranged from

urban parks to multi-use trails and a multifunction sports complex. Participants were in

the United States, with each located in a different geographical region. The participants

were assigned pseudonyms (i.e., Participant A, Participant B, and Participant C) to mask

their identity, which are used throughout the remainder of this study when referring to

participant responses. Specific information related to participants’ therapists, including

therapist demographics and locations where therapy occurred are also vaguely described

to mask participant identity.

Data Collection

Data collection consisted of semistructured interviews. I scheduled a single

interview with each participant at the participants’ convenience with 2 hours planned to

allow time for an in-depth interview; however, interviews were completed in

approximately 40-45 minutes. None of the participants were located in my geographical

area, so I did not conduct any interviews in person. I conducted interviews via the Zoom

online videoconference platform. I used the Zoom platform to record video and audio,

and I also used alternate audio recording devices consisting of a digital recorder and a

LiveScribe pen. I used these recordings to transcribe the audio interviews into written

transcripts. After transcribing these interviews that had been edited to remove excessive

verbal fillers (i.e., “um,” “like,” “you know”), and brief side discussions not pertinent to

walk-and-talk, I forwarded copies of the individual transcripts to participants to review

for accuracy and to add additional insights they might have regarding their walk-and-talk

therapy experiences. Participants approved their transcripts with no additional comments.

I conducted the interviews without incident and participants expressed their enthusiasm

for the opportunity to participate.

Data Analysis

Data analysis was conducted using the seven-step, modified van Kaam approach

for phenomenological research (Moustakas, 1994). Data analysis was informed by IPA

traditions of phenomenology, hermeneutics, and idiography (Smith et al., 2009), wherein

I focused on how the participants, or coresearchers (Moutstakas, 1994), attempted to

make sense of their experience with walk-and-talk therapy from their individual frames

of reference, while also focusing on a specific phenomenon through a small, homogenous

sample (Smith et al., 2009). In addition, I considered how these participants recalled and

made meaning of the separate aspects that comprise the whole experience of walk-and-

talk therapy. Finally, during the process of data analysis, I also gave attention to the

informing conceptual lenses of this study including the therapeutic frame (Jordan, 2013;

Jordan & Marshall, 2010; Langs, 1979) and biopsychosocial model of health (Wade &

Halligan, 2017). In accordance with both IPA and modified van Kaam protocol, I

analyzed individual participant data separately before combining and synthesizing results

(Moustakas, 1994; Smith et al., 2009). I used Excel spreadsheets and manual coding to

list and categorize participant responses for the first four steps of the modified van Kaam

method of analysis. In addition, in accordance with IPA principles, I was mindful during

these and subsequent processes that, as researcher, I was attempting to make sense of the

coresearchers making sense of their experience (Brocki & Wearden, 2006) of the frame

of walk-and-talk therapy. Descriptions and results from the analysis steps, including a

composite textural-structural description of the phenomenon of the frame of walk-and-

talk therapy from the clients’ perspective are addressed in the Results section.

Evidence of Trustworthiness

Credibility

To establish credibility, or internal validity, and ensure the findings and

interpretations of this study were reflective of the phenomenon of interest (Merriam &

Tisdell, 2016; Moustakas, 1994), I used various methods such as prolonged contact,

triangulation, member checks, and reflexivity. I accomplished prolonged contact (Smith

et al., 2009) through in-depth, semistructured interviews of a small, homogenous sample,

and I encouraged participants to e-mail or call with additional insights later. I

accomplished triangulation through member checking (Maxwell, 2005; Merriam &

Tisdell, 2016) by having participants verify the content of their transcripts for accuracy

and asking for further clarification or insights. Participants confirmed that the transcripts

were accurate descriptions of their experience of walk-and-talk. I also used second tier

triangulation by cross-referencing the current knowledge base and my professional

experience during the structural description and synthesis phases (see Smith et al., 2009).

Throughout the data collection and analysis phases I exercised reflexivity by attending to

my bias as a walk-and-talk therapist and considering other possible explanations of the

observed phenomena (see Merriam & Tisdell, 2016; Moustakas, 1994). Interview

questions were open-ended and non-leading, and I asked clarifying questions to allow

participants to communicate their perspectives (see Miles et al., 2014; Patton, 2015;

Smith et al., 2009). I also noted differences between client accounts of their experiences

of walk-and-talk to increase credibility of findings.

Transferability

Transferability, or external validity, is a limitation in IPA studies because the

sample is typically small and homogenous (Smith et al., 2009). This study had a small

sample size, so it is not possible to generalize findings to larger groups or populations

(Merriam & Tisdell, 2016). However, I used second tier triangulation to synthesize

participants accounts with my professional experience and the current literature from the

therapists’ perspectives (Leung, 2015), thereby contextualizing participant experiences

(Merriam & Tisdell, 2016; Smith et al., 2009) and increasing the possibility of

application to similar populations.

Dependability

Dependability was accomplished both by the triangulation processes (Leung,

2015) and by maintaining an audit trail (Merriam & Tisdell, 2016). Throughout the

recruitment process, I maintained an Excel spreadsheet containing dates of contact

attempts with walk-and-talk therapists, follow-up e-mails and phone calls, and therapist

responses. I also maintained a record of participant contacts and responses, dates of

consent, and interview dates. During the data collection process, I adhered to the protocol

regarding semistructured interview format, allowing for participants to elaborate on

aspects of their experience they deemed important as they attempted to make sense of

their experience while making sure to prompt them to further describe specific

components of walk-and-talk therapy and specific aspects of their experiences. I further

promoted dependability through member checking (see Merriam & Tisdell, 2016;

Moustakas, 1994).

Confirmability

To increase confirmability and maintain objectivity, I exercised reflexivity

throughout the data collection and analysis process, bracketing known bias from the start

and attending to additional bias as it arose (see Maxwell, 2005; Smith et al., 2009). I

maintained a curious stance and asked participants to elaborate on their answers, being

mindful of alternate explanations (Merriam & Tisdell, 2016; Moustakas, 1994; Smith et

al., 2009). I was mindful that I was attempting to make sense of the clients’ experience as

they were also attempting to make sense of their experience (Smith et al., 2009), and I

noted and addressed personal bias as it surfaced. I also exercised imaginative variation

during the analysis phase (Moustakas, 1994), considering alternate explanations apart

from my bias influenced by my professional experience and knowledge.

Results

The seven steps of the modified van Kaam method were used for data analysis.

See Appendix B for samples of the horizontalization outcomes for each of the

participants. Overarching themes and invariant constituents are presented in Table 1.

Individual textural descriptions are detailed in the following sections, as are highlights of

the individual structural descriptions.

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Table 1

Invariant Constituents

Invariant constituents/themes

Prior experience in traditional

therapy

Participant Participant Participant

Unfamiliarity with walk-and-talk X

Self-selection to participate

Invitation to participate in walk- X

and-talk

Initial reluctance

Initial awkwardness

Concerns

Characteristics of setting:

Therapeutic

relationship/engagement

Client agency

Informed consent

Mind-body experience

Comparison to traditional

Enjoyment/therapeutic benefit

Walk-and-talk as alternative

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Participant A Textural Description

Having previously participated in traditional, in-office therapy, Participant A

learned about walk-and-talk therapy from her therapist. She was not knowledgeable about

walk-and-talk before her therapist’s invitation, and she did not self-select to participate.

Her therapist “was doing walk-and-talk, so it was sort of random.” Participant A’s

relationship with her therapist was a mitigating factor influencing her decision to

participate. “I clearly wouldn’t have even considered doing the walk-and-talk originally

unless I really got a lot from her and enjoyed working with her. If it was someone else, I

probably would have said, forget it. I’ll just find somebody else.” In addition to this

therapeutic alliance, scheduling concerns dictated her decision to participate. “I really

liked my therapist, so, if I wanted to keep seeing her, in the time that was convenient for

me I basically had to do the walk-and-talk.”

Participant A described the setting of her walk-and-talk experience as a trail “that

got a little crowded depending on the time of day” with early mornings being especially

popular for joggers and commuting bikers she described as “aggressive.” Appointment

scheduling depended on weather and temperature with most scheduled for early morning

to accommodate her work schedule and to avoid extreme heat or cold because “it would

stress [her] out if it was very cold or very hot.” She was averse to rainy conditions as well

“because it’s bad for [her] hair.” Participant A cited additional logistical challenges

including scheduling around having to “change, shower, or whatever before or after” and

figuring out how to carry “a water bottle and then your phone,” but she reported these

challenges were “manageable.”

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Participant A had some initial reluctance. “I work out sometimes, but it’s only

because I have to, so I wasn’t super excited about walking and being outside.” Other

reasons for this reluctance included “having to get to work and shower.” She also

described awkwardness with walking side-by-side instead of sitting face-to-face. “At first

it was kind of weird for me ’cause I felt like I should be looking at her and talking.”

Other concerns Participant A had included concerns about seeing people she knew and

fearing “they would somehow know all of [her] problems.”

Working through scheduling and logistical challenges provided opportunity for

Participant A to work collaboratively with her therapist. “I do know if it was raining I

didn’t like to go and walk in the rain so we would change and just talk inside.”

Participant A’s therapist allowed her to set the walking pace that she defined as “not

jogging, but just walking very fast.” In addition, Participant A indicated she had input in

the location of her outdoor therapy sessions as the walking path was “mutually agreed

upon . . . because it was convenient” for the both of them and “equidistant” between work

and home.

Participant A reported that talking while walking side-by-side became “perfectly

comfortable.” She also expressed that she never did see anyone she knew, but even if she

had it likely would not have mattered because “everybody who is walking out there is

going about their own business anyway.” She came to understand that others would likely

view her outdoor session as “friends” out for a walk. She realized that others could see

her walk into the office building where her indoor appointments occurred, therefore,

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“there’s no difference,” and her concerns about others seeing her out with her therapist

were unfounded. “That was stupid. So, I got over that right away, too.”

Participant A described her experience as a whole-body, multi-sensory experience

where her “brain was moving faster with the rest of [her] body that was moving,” and

incorporated her “whole body involved in what [she was] trying to solve.” She described

how participating in therapy outdoors while walking helped solidify the content of her

therapy sessions:

I think it just made it stick. You know, you can talk, and talk, and talk about

something, but when you’re walking and talking . . . I felt like, for me at least, it

made my ideas a little better, and my commitment to go out and do the things we

talked about stick. I would go out and do it because it’s baked into my muscle

memory. And when I would go out, and I’d have images in my mind of where we

were walking when we were talking about something, and how things smelled, or

the sound of the train going by, or the bird or something, and that those would be

kind of like very positive triggers for me to remember the point of the therapy and

what I wanted to get out of it.

She further commented that, “sometimes, when I walk the dog, or whenever I have

occasion to just go out walking by myself . . . I kind of default back to the walking

therapy and some of the advice she’s given me to kind of think through problems I might

be having.”

Although she described the natural component of her outdoor therapy as merely

“backdrop,” she mentioned that it reinforced some of the content of her therapy sessions

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as well. “I don’t know that this was intentional, but, even today . . . it’s been years since I

started doing it . . . I can still remember exactly where I was when we talked about certain

things…I can close my eyes and remember that and there’s comfort to that.” She also

expressed belief that office spaces are “artificial” and being outside allowed for more

freedom of expression. “As comfortable as you try, people try and make their offices, it’s

still an office. And when you’re outside, I think that the unlimited-ness of outside . . . you

can see the sky, you can see the trees, you can see forever . . . I think kind of frees your

mind a little bit, too.”

Participant A described that physical activity during walk-and-talk therapy

provided numerous benefits including improved mood. “It was nice to get a workout in as

well. It felt good after that.” She also reported increased energy evidenced by “that kind

of high feeling . . . just ready to go do more stuff.” Finally, she described improved

cognition. “I don’t know if it’s, like, hormonal or chemical when you’re walking around,

but, I just feel like I could think more clearly as I was moving.”

Participant A appeared to try to make sense of her walk-and-talk experience by

comparing it to her prior indoor therapy experience. She described her walk-and-talk

sessions as “more natural, less forced being outside and walking instead of just having to

sit there.” Returning to the office on occasion “just wasn’t as dynamic. It almost gets kind

of boring just sitting there.” She described subsequent indoor sessions sitting face-to-face

as “harder.” She described walk-and-talk sessions as less formal “because you’re not

dressed up or sitting in a chair and there’s not a box of Kleenex nearby. You’re just

walking which is something everybody does. There’s nothing unnatural about it.” She

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concluded this informality made talking “easier” and reflected on how it increased her

honesty and vulnerability. “It just made me feel like my armor was off ’cause I wasn’t

wearing my work clothes. So, I felt like I was going in a little more vulnerable . . . in a

good way . . . than I had been before.” She described making the change to walk-and-talk

therapy “mentally helped me express myself . . . be a little more honest and vulnerable

having stripped down to just like wearing workout clothes . . . and knowing I was going

to get hot and sweaty, and not caring what I looked like.”

She also mused about not remembering crying while outside. “I don’t know what

I did, which is weird, because I did a lot of crying when we were in, and the same things

were in effect so maybe there was like no crying outside?” She further pondered how the

movement may have influenced this phenomenon. “Like I said before, when your whole

body is in motion . . . you can’t crawl into yourself and your sadness, you know? You can

still be sad and emotional, but . . . I just didn’t have to cry anymore.” However, she did

conclude, “maybe I did cry. Maybe it just wasn’t sobbing where I needed a box of

Kleenex.”

Responding to whether walk-and-talk affected her relationship with her therapist

Participant A reflected, “I liked her a lot before and then liked her a lot after. I don’t

know that it changed.” Overall, Participant A described her walk-and-talk experience as

pleasant, something she “enjoyed,” and to which she “looked forward.” Despite initial

reluctance she indicated, “the first time I did it I was a convert.” Finally, Participant A

pondered whether walk-and-talk might be a worthwhile therapeutic option for individuals

who are more active and would “have trouble just sitting still and talking.”

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Participant B Textural Description

Participant B had many years of experience with traditional therapy in an indoor

setting before learning about walk-and-talk, and at that point she was in a new location

with a fairly new therapist. She did not self-select to participate and was surprised to

learn about it, responding to her therapist’s invitation with, “Oh, that’s cool. I didn’t even

know it was a thing.” Participant B’s therapist had recently begun offering walk-and-talk

therapy and “messaged [her] one day before a session and said, Do you want to meet in

the park today?” Having not heard of walk-and-talk before, she found the idea of it

“fascinating,” but “also a little bit of an eyebrow raise. Like, Really? We’re going to go

walk around in the park and have therapy? Is this really a thing?” Her initial response

was twofold—on the one hand, she had reservations. She had recently relocated from a

more “staid, pragmatic environment” to a city she referred to as “woo woo” with various

“different modalities” that she appreciated, but to which she was not accustomed. On the

other hand, her self-proclaimed sense of adventure helped spur her to participate. “I’m an

experimenter, and I like to try new things . . . and I like to be outside. I’m an outdoorsy

type. I didn’t feel like it hurt . . . and so it just was kind of, Why not?”

Despite her willingness to engage in walk-and-talk therapy, Participant B did

continue to have concerns about whether it would be “super therapeutic.” She also

worried about addressing more serious topics. “I was concerned at first that it wouldn’t

be therapeutic or that I wouldn’t feel like talking about serious . . . getting into the nuts

and bolts of things because I’m out in public. And I don’t want to cry in public.” Her

initial concerns were based on what she deemed “some sort of old-school ideas about

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what [she] expected.” Another similar concern was related to worry over being able to be

“authentic” during walk-and-talk sessions. “I guess I just want to be in an environment

where I can be authentic with my reactions, and I don’t know if I can do that when we’re

outside in public walking around.”

Over the course of her outdoor sessions Participant B developed further concerns

about being distracted from the content of her sessions and losing her train of thought. “I

feel like I’m on a good run and then we get distracted by a dog or a bicyclist, or

whatever, and I lose my train of thought. I may or may not pick it up again. I guess I

would not want to lose that train of thought even for something as adorable as a dog.”

She also expressed a concern about running into others she knew because she did not

want to have to stop and talk and take time away from her sessions. “It was in the back of

my mind, like, oh my God, the clock is ticking. This is my hour and I don’t want to waste

it. I feel like every minute with my therapist is precious.” Upon running into people she

knew a couple of times during outdoor sessions she reported being concerned about “how

quickly can I extricate myself from this situation so that I can go on with my session?”

Some of Participant B’s concerns were addressed as her therapist gave her voice

and agency in decision-making around her sessions. Although she quickly came to realize

her therapist was “always up for walking. It [didn’t] matter the weather. She’s always up

for it, no matter what,” her therapist left the decision about being indoors or outdoors up

to her. “Most of the time it was a game-day decision. She’d text me in the morning to

confirm the appointment . . . and I’d just respond with whatever I wanted . . . with my

choice. So, it was kind of nice I got to make the decision on that day.” Her reasons for

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occasional preference for being indoors included feeling like it might be a “heavy-duty

session” and she might cry. She also mentioned a desire to take notes. “Sometimes I

wanted to be in the office because I can write down what we’re talking about or give

myself homework or something. You can’t do that when we’re walking.” Otherwise she

would “opt outside weather permitting, and as long as [she] didn’t have anything earth-

shattering that [she] needed to talk about . . . which was most of the time.”

Participant B’s therapist also gave her agency in choosing where her outdoor

sessions occurred. The location was one of two parks located conveniently to her home

and work. She described the settings as “beautiful parks with walking paths, and one of

them [had] lakes and ducks, and one [didn’t] . . . but just beautiful, green, grassy, trees.”

Although she initially expressed equal satisfaction with both parks, she later described a

preference for the one that was “just a little bit farther away” from her home because she

was “not as concerned about running into neighbors.”

Participant B was attentive to the relationship she had with her therapist. She

found it easy to engage and had a good rapport with her therapist “by the end of [their]

first session” that she also attributed to voluntarily “putting [herself] in therapy.” She felt

her therapist demonstrated engagement and attention to the relationship indoors and

outdoors, but she felt her therapist had to work harder at demonstrating that engagement

during walk-and-talk sessions. “She’s awesome, but when we were walking, I guess I

realized that it probably takes more effort for her to stay, to appear to be engaged in what

I need, or to help me feel that she’s engaged because we’re multitasking . . . navigating

the trails, and keeping track of the time, and watching out for dog-walkers and bicyclers,

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and things like that. I always felt like she was still, really with me.” She commented

feeling like her therapist was “more engaged because we were walking” despite lack of

eye contact while walking side-by-side. “It’s obvious when you’re sitting in an office and

she’s making eye contact. She’s paying attention and she’s taking notes. That’s obvious

that she’s there for me, but I still felt that way when we were out walking, even though

we would barely make any eye contact at all.” Participant B questioned whether walk-

and-talk might be “a great entre for someone who is not especially motivated for

therapy?”

Participant B repeatedly referenced her indoor therapy sessions when describing

her walk-and-talk therapy experience. She indicated having been “in and out of therapy”

for a number of decades, that she would “always return to it,” and reported that this last

return to therapy was just for “emotional tune-ups.” The lesser severity of her concerns

for which she returned to therapy this time influenced her willingness to participate in

walk-and-talk. “If I had been going for anything other than just emotional tune-ups . . . I

would probably prefer to stay in office just because less distraction.” Although

Participant B requested to be in the office on days she felt she might need to cry, she

recognized, “it didn’t always happen. I could never predict it.” Despite being cautious

about being outside when she believed her session content would be more intense or

emotional, Participant B indicated, “I never cried when we were out walking around.”

Continuing to compare with her indoor experience she reported, “There were times in the

office when I would lose it and be crying, but I didn’t ever have that experience outside.”

Trying to make sense of this phenomenon she commented, “I didn’t ever have to try and

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stop myself crying when we were outside. It just never came up when we were out there,

and so I don’t know if it didn’t come up because we were walking, or if it didn’t come up

just because it doesn’t always.” She also recounted that, “If I wanted to stay in the office

’cause I thought it was going to be a heavy day, usually it just was in my head.”

In addition to noticing that she did not cry outdoors, Participant B reflected on

ways in which she experienced a mind-body connection during her walk-and-talk therapy

experience, indicating she never felt “stifled when we were out walking around, like [she]

couldn’t do or say whatever [she] wanted.” She also reported she was never “at a loss

really for things to say when we were walking.” She indicated that outdoor sessions were

somewhat easier “because you’re not just sitting there staring at each other across the

room” and “sometimes in the office maybe I would feel pressured to come up with

something.” She pondered whether “other things came up to talk about because [they]

were moving and being active.” She recalled that she and her therapist “could have just

sat outside instead of walking around.” She commented, “I don’t know if that’s the

physical activity that kept . . . my thoughts flowing better. I don’t know.”

Participant B appreciated the ability to combine therapy with physical activity.

She opted for taking her sessions outdoors on days when she also wanted to “get a little

exercise and some fresh air” and when “the sidewalks were clear and we didn’t have to

slop through any muck.” She even attempted to combine one therapy session with

walking her dog, but quickly decided that was a bad idea as it was “distracting” because

others “were coming up and constantly commenting on the dog.” In addition, Participant

B lamented other outside distractions. She had concerns about running into others she

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knew and chose the location where this was less likely to happen. Although her therapist

addressed this possibility prior to it happening, and asked her about how she would like

to handle it, Participant B still worried that keeping her responses with others brief in

order to get back to therapy may have appeared “rude.” She indicated that she was not

afraid for others to know she was in therapy, but introduced her therapist as her “friend”

in order to lessen awkwardness for others.

Overall, Participant B concluded that her walk-and-talk sessions felt very

“natural” and “normal.” Addressing her initial reluctance with walking-and-talk,

Participant B reflected, “I didn’t feel like it hurt . . . it didn’t really take away from the

therapeutic value of the session.” Although she did counter with, “but some of our best

work was done in the office.”

Participant C Textural Description

Participant C enthusiastically embraced walk-and-talk therapy upon learning

about it from a friend. She had prior experience with “traditional, in-office therapy” she

described as “your classic, office, couch scenario,” but felt she “got off on a bad foot with

the office setting to begin with.” She described one indoor setting where the therapist

“had essential oils going with a diffuser, and playing classical music, and the lights were

dimmed,” indicating it was like “stepping into a movie . . . very strange, and not at all

casual and comfortable to talk about my feelings.” For this reason, she felt like walk-and-

talk was “just a brilliant idea” and self-selected to participate. She recalled that if she did

not “feel comfortable in a room setting maybe something more natural would be better

for talking. That was on purpose. It just seemed like a better option.”

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Participant C’s walk-and-talk therapist conducted their sessions at a multi-

function sports complex with a walking pathway around a park with “a big grassy area

with lots of trees.” Although there were some “patches where there was mostly asphalt,”

there were plenty of natural components. With the exception of one brief phone session

all of her sessions with this therapist were “meeting and walking outside.” Participant C

noted that this setting was often “a very busy place” with “a lot of people using the loop

as well . . . to get in a work out.” She commented that it was not an “overwhelming

amount of people,” but that they “always had people in sight” and were “constantly

walking by people.” She mentioned that at times when they were “walking at the same

pace as someone” they would “jog for a little bit to get past them and then start walking

again.” Despite the number of people they encountered during their sessions, Participant

C reported that it “wasn’t really a hassle” and the “hustle and bustle . . . felt very natural.”

From the beginning, Participant C compared her prior therapy experience with

walk-and-talk therapy. She indicated that she did not “personally agree with the stigma

behind therapy” but knew that it existed. In the past she noted that she was “very nervous

about it, ’cause what if people see me walking up here? I don’t know what they’re going

to think.” She felt that participating in walk-and-talk helped “take that sort of stigma

away,” because the setting was “very natural to go there” and she would not “stand out

by being there.” She mentioned that there were “tons of other people there, chatting with

their friends, or walking, or on a run, or with their dogs. People were there for all sort of

reasons, so I felt normal going there.”

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Participant C described initial awkwardness “getting to know” her therapist,

because “meeting anyone for the first time is a little bit awkward;” however, she did feel

like “connection with [her] therapist” happened more quickly with her walk-and-talk

experience. The conversations she had with her therapist “getting out of the car and

parking, and getting into the car” felt “very normal” and helped her get to know her

therapist better than she had known any of her prior therapists. She knew their

relationship “was built around the help that [she] was seeking,” and that her therapist

“genuinely cared about [her] as a client, but as a person as well. And that’s not something

that [she] felt with any other experience.” Participant C commented, “I didn’t feel like it

was super easy for me to talk to my [previous] counselor just because it was kind of a

forced setting.” She iterated that “walking side-by-side really helped me get what I

wanted out of the experience faster by kind of making me feel more comfortable so that

we could progress together faster.” She felt comfortable with her therapist more quickly

because their relationship was not “just associated with this professional, doctor/service

type thing.”

Although Participant C purposefully self-selected walk-and-talk therapy, she still

had some concerns. Weather and temperature were a concern because it could get “pretty

hot sometimes,” but she “would always dress in workout clothes” and “was prepared to

probably sweat a little bit.” She did not recall rain ever being an issue, and she wondered

how they might have handled things if it had rained. Participant C recalled being

“strategic” about scheduling “before the sun would come out, or after it would go down”

to avoid the heat of the day. Her therapist handled other potential concerns with a detailed

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informed consent and allowed Participant C agency in many of the decisions regarding

her therapy experience. She recalled signing a document “that [she] agreed to what [she

was] doing in terms of the exercise, and that it was a walk, and there was [sic]

accommodations to be made if that was needed.” She also described her therapist

reviewing risks and benefits of walk-and-talk including “there could be unexpected

things that happened.” She likened this informed consent process to “commercials where

they list all of the side effects.” She also had a choice in whether she “wanted to just be

outside in nature” or if she wanted to include physical activity. She also had a choice in

“which pace [she] thought would fit [her] best” and expressed preference for the outdoors

because “just physically getting outside, even if it’s not for walk-and-talk therapy, is a

good thing by itself.” She also mentioned scheduling sessions late in the week as a way to

“sort things out and have a debrief at the end of the week.”

Participant C’s therapist’s informed consent also addressed encountering others

they might know in the busy environment where her sessions occurred. She recalled she

“never really had a concern” with being around others in public because her therapist had

“never had an issue” with it, telling her, “everybody here is basically just here to either

enjoy the park or workout.” Because her therapist was up front about this, she recalled

not feeling “super freaked out when we saw people.” Upon encountering others, they

knew they “stopped and said, Hello,” but it was not bothersome. “I could have been with

anyone. There was no association behind what I was doing or what they were doing, and

they were just really quick interactions.” These brief encounters did not disrupt her

therapy sessions. “It wasn’t really an interruption. It was super easy to pick back up

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where we left off.” She mentioned, “It was very natural. We kind of just kept walking . . .

and then it was just a pause.”

Participant C articulated a number of benefits of her walk-and-talk experience.

She iterated that it was more “personable” and that walking side-by-side helped her feel

“more comfortable to actually articulate and think about what [she] was going to say.”

She described the frame as providing her time to think, “because it wasn’t forced.” She

described her sessions as “casual,” and feeling “like two friends going to a park to catch

up.” She even described feeling more “equal” and like she was “on the same playing

field” as her therapist. She felt the setting allowed her to “connect” with, and get to know

her therapist more quickly, calling her experience “easy” and more “conversational.”

Specifically, Participant C described walking side-by-side as less “awkward” allowing

her freedom to not “overthink” what she was going to say, or to feel less pressure if she

needed to “take a break from talking.” She even mentioned, “If I needed a second to grab

my thoughts, we’d just look around and see cute dogs.”

Participant C described other benefits including feeling “productive” while

combining her weekly therapy session with a “pretty fast” walk. She described feeling

“satisfied” with the content of her sessions, and feeling “happy at the end” knowing she

was “learning tools to deal with stress” and making “progress” that also served to boost

her confidence. She especially appreciated the combination of physical activity and being

outside because of the sedentary nature of the rest of her weekly activities and “being

stuck inside.” Participant C made a connection between the physical activity and her

thoughts and mood. “You are also exercising and stimulating your body and stimulating

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your mind by being outside.” She commented, “Exercise in general stimulates your brain

in a different way. It like sends different hormones and endorphins and things throughout

your body” and provides “a different way to get your brain thinking.” She recognized the

ways in which walk-and-talk was “relaxing,” “calm,” and “refreshing” in the natural

surroundings, as well as leaving her with a “good kind of afterglow feeling” post session.

Although Participant C described the natural setting of her sessions as backdrop, she did

feel that it “subconsciously helped with the relaxing part.” She mentioned that although

clinicians often attempt to decorate their offices with artwork reflective of nature,

“nothing beats the real thing.” More than once she commented on the importance of the

natural, outdoor setting saying, “it would have been a completely different experience if

we were walking inside a track at a gym or something. It would have been very different

to have been doing the same intensity walking in a different setting.” Participant C also

felt walk-and-talk therapy helped her internalize the content of her therapy sessions. “I

think the movement part kind of made me more aware of my actions . . . which kind of

helped me to keep what we talked about during the sessions something that was easy to

remember, and to bring with me after that and apply what we had actually talked about.”

Whereas, Participant C would often dread her traditional, indoor therapy sessions,

“because it was a big ordeal,” she enjoyed and anticipated her walk-and-talk sessions.

“This was something that I really looked forward to, and I remembered, and it was a

really, really great way to kind of change my counseling experience.” She recalled that

walk-and-talk was “definitely just an easier experience than any office setting I think

could ever provide.” Although she recognized that walk-and-talk might not be suited for

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everyone, she believed it to be one of “many different options” for others. She indicated

walk-and-talk was now her “go-to thing to recommend.”

Participant A Structural Description

Participant A described synergistic benefits of engaging her mind, body, and

senses in the walk-and-talk therapeutic process. She became aware of improved cognition

evidenced by clarity of thought during sessions, and improved mood and increased

energy at the conclusion of her therapy sessions. She found it puzzling that she did not

remember crying during outdoor, walking sessions, further supporting her belief in the

mood boosting effects of adding physical activity and nature exposure to her therapy

experience. In addition to the immediate benefits experienced during and after her

therapy sessions, Participant A felt the physical activity and natural surroundings

heightened and coalesced her therapeutic experience, and even now she remembers

content of her therapy sessions and the sensory stimuli she experienced at the time.

Though she engaged with hesitation, the essence of Participant A’s lived experience of

walk-and-talk therapy was that it was challenging yet transformative. She developed a

preference for walk-and-talk and enjoyed and anticipated her sessions.

Participant B Structural Description

Participant B’s experience with walk-and-talk therapy was peppered with

ambivalence. On the one hand, she expressed appreciation for the experience and some of

its benefits, in particular the relationship with her therapist. On the other hand, she

preferred being indoors, especially when and if her sessions might be intense or

emotional. She equated her enjoyment of walk-and-talk with having volunteered for

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therapy for emotional maintenance. She appreciated being outdoors and being able to

combine her therapy session with physical activity; however, real or potential distractions

prevented her from always enjoying a safe and secure outdoor therapy frame. She

indicated her walk-and-talk therapy experience was as therapeutic as her indoor

experience, although she repeated her reasons for therapy this time around were less

severe. She also referenced having recently moved from a more traditional and

conventional environment. Cultural norms and the extended length of time Participant B

had been in therapy off and on over many years may have contributed to an expectation

of traditional therapy norms.

Participant C Structural Description

Overall, Participant C enjoyed her walk-and-talk experience and anticipated her

sessions. She believed the benefits she gained from walk-and-talk were far greater than

what she experienced with past therapy experiences. Although her positive walk-and-talk

experience may have been predicated by her expectations based on her awkward past

therapy experiences, Participant C did report that the outdoor frame was more

comfortable, safe, and therapeutic for her. Her youth and recognition of the importance of

including physical activity and elements of nature in her everyday life may have also

predisposed her to a preference for an outdoor frame. Participant C is now a proponent of

walk-and-talk therapy and recommends it to others reluctant to engage in indoor therapy,

or for those who, like her, have not had positive traditional therapy experiences.

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Composite Textural-Structural Description

After completing individual textural-structural descriptions for each participant, I

composed a composite textural-structural description as the final step of the van Kaam

data analysis process. In this composite, I describe the essence of the coresearchers’

walk-and-talk therapy experience.

Prior therapy experience. The essence of the frame of walk-and-talk therapy

may be better understood from the perspective of the clients who have engaged in the

practice. Clients are likely to make sense of walk-and-talk through the lens of their prior

traditional therapy experience. The coresearchers in this study had participated in

traditional, therapy and described the essence of their experience of walk-and-talk

therapy through the lens of these past experiences. In addition, participants framed their

walk-and-talk experience by amount of time they previously spent in therapy, their

relationship with their therapist, and whether their earlier experiences in therapy were

positive or not.

Unfamiliarity with walk-and-talk. Two study participants had not heard about

walk-and-talk therapy until their therapists invited them to participate. These clients were

content with their prior indoor therapy arrangement, had no knowledge of walk-and-talk

to date, and were not seeking a new therapy experience. The third participant was

informed of walk-and-talk by a friend.

Invitation versus self-selection. For the two clients who were invited to

participate by their current therapist, the impetus to participate varied. One expressed a

sense of adventure and willingness to try something new, whereas the other valued her

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relationship with her therapist, and knew that she had to agree to walk-and-talk or find

another therapist that could meet with her within the confines of her work schedule. Both

had a strong therapeutic alliance and therefore felt more inclined to accept the walk-and-

talk invitation; however, inherent in this was the possibility that the therapist-client power

differential may have produced some influence. Although neither overtly expressed

coercion to participate, the initial reluctance they both felt coupled with their relationship

with their therapists suggested an underlying fear that if they opted against walk-and-talk

they would either have find a new therapist, or they risked harm to their current

therapeutic alliance.

Conversely, the youngest study participant was encouraged by a friend to try

walk-and-talk. Having prior traditional therapy experiences she considered strange and

uncomfortable, she enthusiastically self-selected to participate in walk-and-talk, and

expected it to be a better fit for her. She may have also been more inclined to participate

in a new and novel experience because of her youth.

Initial reluctance. Two participants responded to walk-and-talk with

ambivalence and initial reluctance. These two participants had concerns about whether it

would be therapeutic, concerns about being outdoors in the elements, and concerns about

running into others they might know. Yet they agreed to participate with minimal

enthusiasm. Some of their ambivalence may have also stemmed from being unfamiliar

with the practice and not self-selecting to participate. The third participant who self-

selected walk-and-talk did so without hesitation.

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Characteristics of setting. Although the outdoor settings varied, including

multiuse trails, a multi-function sports complex, and urban park settings, the settings had

natural components, and other pedestrians and commuters (i.e., bicyclers) used the spaces

at the same times as therapy sessions occurred. Therapy settings were conveniently

located to participants’ home, work, or other activities. Participants agreed that the

natural components of their walk-and-talk therapy settings were backdrop and their

therapists did not actively incorporate the natural elements into the work of therapy;

however, two of the participants expressed that those natural components enhanced their

outdoor therapy experience.

Therapeutic relationship. Coresearchers described good rapport with their

therapist before being invited to participate in walk-and-talk therapy, or they rapidly

developed rapport after self-selecting to participate. Study participants also described

engagement with their therapists throughout the process, whether they returned indoors,

or remained outdoors for their therapy sessions. The therapeutic alliance may have

enhanced the walk-and-talk experience and lessened the impact of deviations in the

altered outdoor frame.

Initial concerns. Participants approached walk-and-talk therapy with various

concerns, including logistical concerns such as scheduling around work and other

activities. Weather and temperature were also considerations for participants that dictated

session location and timing. Participants also vocalized concern over the presence of

others in their walk-and-talk therapy environment. Participants alluded to a concern for

confidentiality and an understanding of the stigma associated with therapy. For one

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participant, however, encountering others she knew was more of a concern because it

infringed upon her therapy hour. Although she felt comfortable introducing her therapist

as a friend, she wanted to quickly return to her session without appearing rude. This

participant also expressed frustration with other distractions because they would derail

her thought process. An additional concern was fear of becoming emotional during an

outdoor session. One participant also desired authenticity in her reactions in session and

feared losing control in public. This participant indicated a preference for being indoors

on days she believed her session content would be more intense or she felt she might cry.

This speaks to clients’ desire to have a safe space to explore and experience the full

spectrum of their emotions without others witnessing or judging. Each of these concerns

were issues related to the altered, and often unpredictable nature, of the frame of being

outdoors, with the potential for detracting from the therapeutic value of walk-and-talk.

Informed consent and client agency. Therapists addressed client concerns both

through an informed consent process and by allowing client agency. Participants

scheduled their appointments strategically to avoid extreme hot or cold, or sessions were

conducted indoors if it was raining. Although clients realized their therapists preferred to

be outdoors regardless of weather conditions, they indicated their therapists deferred to

them in determining an indoor or outdoor location. Clients also adapted and dressed for

the weather conditions. The outdoor frame created conditions of physical discomfort for

these clients that might have been detrimental to their walk-and-talk experience.

Allowing for personal agency and having alternate schedule and location options helped

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ease participant concerns regarding logistical issues, and helped them prepare for and

manage potential discomfort.

Walk-and-talk therapists managed concerns for confidentiality and lessened the

clients’ worry over implied stigma in a few ways. The first was through a formal

informed consent process and by informally asking how clients preferred to handle

chance encounters. One therapist normalized the setting and activity level, assuring her

client that it had not been an issue because others were immersed in their own activities.

Over the course of walk-and-talk therapy participants realized that others were not paying

attention to their therapy sessions or the content. They also realized that others could also

witness them walking into their therapist’s office. The participants expressed

understanding that others would view their walk-and-talk sessions as friends out for a

walk, and introduced their therapist as a friend when they encountered others they knew.

Matters of confidentiality and the remaining stigma regarding seeking counseling

are typically nonissues in traditional therapy settings; however, coresearchers recognized

that being seen walking into an indoor therapy office is not without risk. Participants’

concerns were eased when their therapists addressed these issues before their first

outdoor session. In addition, after experiencing walk-and-talk, clients realized others

were attending to their own pursuits and not mindful that they were engaging in a therapy

session. One coresearcher even felt the presence of others in the busy setting helped

reduce felt stigma because the setting and surrounding activity felt very normal.

One client opted for indoor sessions on days when she felt her session content

would be more intense or she would choose the outdoor location that was farther from

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her home to lessen the probability of chance encounters and other distractions. This

client’s experience is important as it highlights other concerns arising from and outdoor

therapy frame. Indoor therapy settings prevent interruption and protect therapy time.

Opting inside solved those issues on occasion, but this was still a very real concern for

this client on the days therapy sessions were outside. Having extensive therapy

experience over a few decades may also have factored into this client’s expectations for a

more strict and protected frame. Her therapist respected her concerns and choice about

the location of her therapy sessions on the day of her appointments.

Initial awkwardness. Another issue mentioned by participants was the initial

awkwardness of walking side-by-side with their therapist. Eye contact is acceptable

etiquette while communicating; thus, clients initially felt strange not looking at their

therapist during outdoor sessions. Yet, the consensus was that talking while walking side-

by-side was easier, more comfortable, less forced, and less pressured. They also

experienced a newfound freedom of expression. While one participant opted outside for

all her sessions save one brief phone conversation, the other two had indoor sessions

interspersed with their walk-and-talk sessions, and therefore, experienced the face-to-

face, static office setting anew. Both felt this reinforced the benefits of walking side-by-

side as they experienced awkwardness returning to a face-to-face setting. The participant

who had self-selected walk-and-talk therapy, and thus only had outdoor sessions with this

therapist indicated that walking side-by-side helped facilitate engagement. Although

walking side-by-side was a deviation from the traditional frame, participants enjoyed it

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and realized benefits including finding it easier to talk and express themselves when not

having to make eye contact with their therapist.

Mind-body benefits. Coresearchers described benefits of the different

components of walk-and-talk therapy including feeling refreshed, relaxed, and calmed by

the outdoor setting. Adding physical activity helped boost and aided with clearer and

improved cognition. Participants reported improved communication with their therapist

and issues surfaced they likely would not have discussed in an indoor setting.

Incorporating physical activity into the therapy session also created increased satisfaction

as participants felt their sessions were more productive as they multitasked therapy with

workouts. One participant also indicated multitasking afforded her a boost in confidence.

Coresearchers expressed a belief in a mind-body, or multi-sensory experience as they

described how walk-and-talk sessions helped solidify the content of their sessions. They

believed features of their therapy settings and the movement helped them internalize and

act upon therapy content at later dates.

Participants noticed that they did not remember crying while out walking. A

secure, indoor therapy space provides privacy and helps reduce client worry about

whether or not they might cry; however, participants pondered that something about the

outdoor therapy experience may have prevented their need to cry. Thus walk-and-talk

may influence a boost in mood; however, one participant mentioned an alternate

explanation that emotional responses are sometimes difficult to predict. Regardless, the

possibility of becoming emotional while participating in a walk-and-talk session in public

is a very real possibility and concern brought about by the altered therapeutic frame.

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Comparison to traditional therapy. Coresearchers compared the frame of walk-

and-talk to the frame of their prior traditional therapy experiences. Participants described

walk-and-talk as less formal and pressured, more comfortable, casual, dynamic, and

natural. They felt it enhanced communication and was equally or more therapeutic than

indoor sessions. One participant believed that her walk-and-talk experience allowed her

to feel more equal to her therapist alluding to a more collaborative therapeutic alliance.

Another noticed that the informality helped her be more honest and vulnerable in her

sessions. Despite significant differences between the frames of indoor and outdoor

therapy, these clients recognized benefits during their outdoor sessions they had not

experienced to the same degree indoors. Removing the trappings of the office space

decorated and controlled by the therapist, reduced the formality of the setting, and

brought about a shift in the therapy relationship and dynamics participants felt more

conducive to the therapeutic process.

Enjoyment of walk-and-talk. The study participants indicated they enjoyed their

walk-and-talk therapy experience and believed it to be as therapeutic, or more therapeutic

than their indoor therapy sessions, although one expressed a belief that indoor sessions

would be more appropriate for more severe presenting issues.

Walk-and-talk as an alternative offering. Study participants expressed belief

that walk-and-talk therapy is an appropriate alternative therapeutic offering for

individuals who may not find traditional, indoor therapy appealing for various reasons.

Composite summary, The walled space and ground rules of traditional indoor

therapy is designed to ensure confidentiality and safety, and facilitate a positive and

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productive therapy experience; however, walk-and-talk clients reported that walk-and-

talk therapy, even with its challenges and deviant frame, provided a more holistic,

synergistic therapy experience comparable to, or better than their traditional therapy

experience. The ways in which their therapists addressed the altered outdoor frame,

including prior informed consent, and working collaboratively with clients to facilitate

personal agency, eased client concerns regarding the deviations in the frame. The

coresearchers reported numerous synergistic, mind-body benefits incurred during their

walk-and-talk therapy journeys, and when compared to their prior traditional therapy they

believed walk-and-talk superior in many ways.

Summary

In this chapter I described the data collection and modified van Kaam data

analysis processes I used that resulted in a description of the essence of clients’

experience of walk-and-talk therapy. I presented the themes and invariant constituents

that emerged, and possible explanations for them, using imaginative variation. Themes

that arose addressing how clients experienced the walk-and-talk frame included

participant experience with traditional therapy, unfamiliarity with walk-and-talk,

invitation versus self-selection, initial reluctance, characteristics of setting, therapeutic

relationship, initial awkwardness, initial concerns, informed consent, client agency, mind-

body experience, comparison to traditional therapy, enjoyment and therapeutic value, and

walk-and-talk as an alternative. I also addressed trustworthiness of the data collection and

analysis process through credibility, transferability, dependability, and confirmability. In

the following chapter I will interpret the findings, address limitations, and implications.

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Chapter 5: Discussion, Conclusions, and Recommendations

Introduction

In recent years, more therapists have added walk-and-talk therapy to their

therapeutic repertoire (DeAngelis, 2013); however, research regarding the practice is

behind its increasing popularity. Although some research exists regarding the practice

from the perspective of walk-and-talk therapists (Charbonneau, 2014; Jordan, 2015;

Jordan & Marshall, 2010; King, 2015; McKinney, 2011), there has not been as much

about clients’ perspectives (Jordan, 2015; Jordan & Marshall, 2010). The purpose of this

qualitative, IPA study was to better understand walk-and-talk clients’ experience of the

altered frame of psychotherapy that occurred outdoors while walking side-by-side. The

results showed that clients were largely unfamiliar with the practice before engaging in it,

and their experiences of it were shaped by prior experience they had with traditional

therapy. Clients experienced initial reluctance, awkwardness, and had concerns related to

logistics, weather, and confidentiality. Their engagement with their therapist, how their

therapist handled informed consent, and how their therapists allowed for personal agency

regarding their concerns about the altered frame helped mitigate many of these concerns.

Clients reported an experience that integrated mind and body, with synergistic therapeutic

benefits equal or better than what they experienced with an indoor frame. They reported

overall enjoyment of walk-and-talk therapy and believed it to be a viable alternative for

others who do not find traditional indoor therapy appealing for various reasons.

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Interpretation of the Findings

Participants in this study, consisting of three former walk-and-talk therapy clients,

described their lived experiences of walk-and-talk therapy and echoed some of the same

benefits and themes previously reported in the literature from therapists’ perspectives.

Participants and walk-and-talk therapists alike referenced their perspectives of the

practice based on their prior experience with traditional indoor therapy. Participants also

provided additional insights based on their subjective experiences of the altered frame of

walk-and-talk therapy.

Walk-and-talk therapy may be conceptualized as merely taking normal therapy

outside (McKinney, 2011); however, some therapists have suggested that there is a larger

dynamic occurring during walk-and-talk (Charbonneau, 2016; Wessan, 2018) like a

spiritual component (King, 2015). Participants alluded to this altered energy with one

calling walk-and-talk “more dynamic,” but participants reported mind–body connections

and increased internalization of therapy content they attributed to the convergence of

therapy, physical activity, and the natural setting. Being outdoors and walking side-by-

side also seemed to create a different therapist-client dynamic. For instance, therapists

have recognized that nature adds another dimension to the relationship, creating a triadic

versus a dyadic relationship, with nature ranging from backdrop to active participant as

well as influencing the process of therapy (Harris, 2014). In addition, therapists

sometimes have a preference for working outdoors (Harris, 2014). Clients in this study

echoed the sentiment that their outdoor sessions were easier, more comfortable, and more

natural, with one client reporting better rapport and a better working relationship than she

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had with her prior therapists. None of this study’s participants alluded to a spiritual

component to their walk-and-talk therapy experience.

Increased use of walk-and-talk therapy may be rooted in younger therapists’

willingness to embrace alternative methods and interventions as well as belief that client

needs shape interventions (McKinney, 2011). In addition, the decision to incorporate

walk-and-talk into a therapeutic practice is often born of the therapist’s desire to be

outside (McKinney, 2011). Though the age of the therapists for the participants was

unclear, two of the coresearchers indicated that walk-and-talk was initiated by their

therapist and not themselves. It is also unclear whether their therapists felt that being

outside and walking was a better therapeutic intervention for these clients or whether it

was therapist preference to be outside; however, therapists allowed for client agency in

making the decision whether to be indoors or outdoors.

Researchers have also highlighted therapists’ perspectives regarding a number of

aspects of walk-and-talk therapy as compared to indoor therapy. Findings included that

therapists believe walk-and-talk therapy to be more casual (McKinney, 2011; Revell &

McLeod, 2016), collaborative (Charbonneau, 2016; King, 2015; McKinney, 2011; Revell

& McLeod, 2016), and helped with engagement and therapeutic alliance (McKinney,

2011; Revell & McLeod, 2016). This information was confirmed by this study’s

participants, who described feeling that their experience was more casual, informal,

comfortable, and normal. Although two clients already had a relationship with their

therapists before embarking upon walk-and-talk, the one client who did not know her

therapist before participating reported feeling as if she built that therapeutic alliance with

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her walk-and-talk therapist more quickly, citing walking side-by-side as being a catalyst

to this process and indicating that she felt more equal with her therapist. It is also possible

that her self-selection and prior excitement about the practice, shaped by her

uncomfortable earlier traditional therapy experiences, may have also fueled quicker

engagement with her therapist. Although participants did not overtly mention feeling as

though their walk-and-talk therapy felt more collaborative, the coresearchers did express

ways in which their therapists involved them in decision making around aspects of their

walk-and-talk therapy experiences including setting, scheduling, and whether to stay

outside or go back indoors based on weather or session content and intensity. In these

ways, participants implied collaboration, at least with regard to planning and logistical

concerns. It is not known whether this same collaboration carried over into session

content, processes, or outcomes.

Because walk-and-talk therapy occurs in a space not controlled by the therapist, it

lays the foundation for a more collaborative relationship and allows opportunities for

therapists and clients to co-navigate the space as well as to incorporate aspects of nature

into sessions. Participants in this study experienced opportunities to collaborate with their

therapists regarding session logistics. Participants also expressed the formality and

discomfort they experienced being in a space designed by and controlled by a therapist,

reporting that being outdoors was more therapeutic and less stigmatizing, also supporting

Charbonneau’s (2016) findings. Clients in this study indicated the natural aspects of their

outdoor therapy setting was backdrop and not actively incorporated into their sessions;

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however, two of them mentioned the ways in which the setting enhanced and solidified

session content.

Despite the client-stated benefits of walk-and-talk therapy, there are some noted

concerns. For example, participants echoed researchers’ concerns about weather

(McKinney, 2011; Revel & McLeod, 2016). Engaging in outdoor therapy leads to

concerns not encountered in indoor therapy spaces such as weather and temperature. In

addition, weather and temperature concerns are likely to vary with the particular region

and session in which a client participates in outdoor therapy; however, clients felt as if

their therapists respected their wishes regarding this matter.

There are also concerns about maintaining proper boundaries during walk-and-

talk (Revell & McLeod, 2016). Participants referenced feeling as if they were walking

with a friend, and others might view them as walking with a friend or they introduced

their therapist as a friend, but they also vocalized understanding that their relationship

with their walk-and-talk therapist was a professional one. Another concern mentioned by

walk-and-talk therapists and pointed out by one participant was difficulty in attending to

therapy content and processes during walk-and-talk sessions (McKinney, 2011; Revell &

McLeod, 2016). One participant mentioned feeling as though her therapist had to work

harder to engage while walking and talking. In making further recommendations for

research, Revell and McLeod (2016) warned against assuming one setting was more

therapeutic than another. Participants’ responses confirmed this as one indicated being in

an outdoor space with plenty of activity felt more normal, whereas another felt it more

distracting. Thus, the therapeutic value of a space and level of activity is subjective,

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which was also mirrored in the literature (Bell et al., 2018; Houghton & Houghton,

2015).

Therapists have further mentioned concern for safety (McKinney, 2011).

Although one participant did mention that her therapist’s informed consent included

reference to possible unexpected occurrences, none of the participants overtly mentioned

nor implied concern for their physical safety. There was also agreement between

therapists (Charbonneau, 2016; McKinney, 2011) and participants regarding whether

walk-and-talk might be better suited for specific individuals, particularly those who have

less severe presenting issues.

In addition to concerns about confidentiality, therapists mentioned challenges

related to emotional regulation (i.e., crying in public) and appropriate ethical practices

(Charbonneau, 2016). However, therapists have suggested that clients worried less about

these issues than therapists did (Charbonneau, 2016). Though participants in this study

reported not crying, or not remembering crying, in outdoor sessions it was a real concern

for them, and one reported preference for being indoors on days she felt she might

become emotional. In contrast, Wessan (2018) reported the client in her case study

released a “tsunami of tears” (p. 17) during her first outdoor session. For participants in

this study, reasons for crying or not crying were likely related to intensity of presenting

issues. Study participants may not have sought therapy for complex traumas and thus the

physical activity or nature exposure incorporated during session was a sufficient dose for

improvement in mood (Carek et al., 2011; Ettema & Smajic, 2015; Shanahan et al., 2015)

at the moment. Concern for emotionality, however, may be client specific, as well as

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setting specific. Being in a more secluded, rural setting may ease clients’ concerns about

becoming emotional in public. The process of completing the informed consent process,

including risks and benefits, may also mitigate client concerns about confidentiality and

emotionality (Charbonneau, 2016). This appeared to be the case for one participant as

well, as did having the agency to opt indoors for the other two participants.

Findings in Relation to Conceptual Lens

Concerns reported by therapists in earlier research related to the conceptual lens

of the frame of therapy (Chalquist, 2009; Jordan & Marshall, 2010; Jordan, 2013), were

echoed by participants in this study. Participants noted diverse ways in which the frame

of walk-and-talk therapy deviated from their indoor sessions including concerns about

confidentiality, stigma, distractions, and worry over emotionality. Although participants

quickly became comfortable with the activity and presence of others, these were very real

initial and sometimes ongoing concerns. In addition, one client pointed out more concern

for session flow and infringement upon her therapy hour. Informed consent and client

agency helped clients adjust and adapt to the altered frame, as did immersion in the

experience over time. However, the deviant frame created opportunity for more intense

therapeutic work as one client described that walk-and-talk allowed her to be more honest

and vulnerable in her therapeutic encounters.

In the absence of walls, issues of boundaries and safety were considered

important considerations for the altered outdoor therapy frame (Jordan, 2013: McKinney,

2011; Revell & McLeod, 2016). The therapist is holder of the therapeutic frame when

conducting therapy outdoors and it is important to be able to maintain fluid, yet

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appropriate boundaries (Jordan, 2013). Participants appeared to understand the client–

therapist boundaries and did not seem concerned for their physical safety, although

concerns over emotionality and confidentiality may have been their way of

communicating concern for emotional safety. One client also noticed the ways in which

her therapist appeared to work harder at engagement through attending to the various

distractions in the outdoor therapy environment, thus alluding to understanding that the

therapist was also working harder at maintaining appropriate boundaries and ensuring a

safe environment for therapy. The belief that the altered frame creates an equal power

distribution (Jordan, 2013) was further supported by this study’s clients.

Clients’ descriptions of the essence of their experiences with walk-and-talk

therapy also supported the second conceptual lens for this study, the biopsychosocial

model of well-being. The altered frame of walk-and-talk therapy potentially facilitates a

more holistic therapy experience (Jordan, 2013), consistent with the biopsychosocial

model of well-being. Clients described the ways in which the combination of physical

activity and nature exposure, along with the content of their therapy and their client-

therapist relationship created a better therapy experience for them. They appreciated the

opportunity to multitask, recognizing the importance of physical activity for their

physical well-being, but also noticed improvements in overall well-being evidenced by

improvements in mood, cognition, energy, and confidence. They further described the

experience as refreshing, calming, relaxing, and providing them with ingrained memories

of their therapy sessions they could access in the future.

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Summary of Findings

In conclusion, findings from this study confirmed walk-and-talk therapists’ beliefs

that there are challenges to be addressed when taking therapy into an altered outdoor

frame, but also additional benefits not realized indoors. While clients believed walk-and-

talk therapy equally or more therapeutic than their prior, indoor experiences, they agreed

that walk-and-talk may be better suited for specific clients, particularly those with less

severe presenting issues. Some of the findings of this study that differed from those from

the therapists’ perspective include therapists’ belief that clients are far less concerned

with confidentiality, stigma, emotionality, and ethical considerations. This may be

because therapists are referencing their clients’ experiences retroactively after clients

have become comfortable with the altered frame.

Limitations of the Study

As expected with a small, homogenous sample typical of an IPA study, this

study’s mere three participants prevent generalization to the larger population (Smith et

al., 2009). Specifically, because participants were Caucasian females, the results of this

study may not be generalized to minority populations or to males, or to broader cultural

contexts outside of the United States. Other limitations include focus on the frame of

walk-and-talk in more urban settings, as well as more remote versus recent walk-and-talk

experiences. Finally, participants contacted by their former therapist and provided with

information to participate may have felt obligation or coercion and therefore provided a

more positive description of their experience.

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Recommendations for Future Research

Recommendations for future research include, but are not limited to, examining

the experiences of a more diverse sample, including males and ethnic minorities, current

walk-and-talk therapy clients, or those with more recent walk-and-talk therapy

experience, as well as examining client experiences of walk-and-talk therapy in more

secluded, natural settings where concerns over stigma, confidentiality, or distractions

may be of less concern. Other recommendations for future research of walk-and-talk

therapy include quantitative inquiry such as correlational studies and multiple regression

analysis controlling for various aspects related specifically to the walk-and-talk therapy

frame (i.e., physical activity, natural setting), as well as client and therapist characteristics

and demographics, client presenting issue, or therapist treatment modality. Other

variables for consideration include informed consent, self-selection to participate, and

prior versus no experience in traditional therapy.

Implications

Positive Social Change

Clinicians are expected to abide by their professions’ standard practices and

ethical codes (AAMFT, 2016; APA, 2010). As such, clinicians should also be trained in

their therapeutic offerings and received adequate supervision (Duros & Crowley, 2014).

Because research regarding the practice of walk-and-talk lags behind its rapidly growing

use, training, supervision, and standard practices are virtually nonexistent (Charbonneau,

2016). This study highlighted some of the issues and concerns clients had with their

walk-and-talk therapy experience as well as some of the ways in which their therapists

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did, or did not address them. Shedding light on these client concerns provides opportunity

for clinicians to consider ethical and practical implications, and to establish protocols and

appropriate informed consent for client comfort and safety for walk-and-talk therapy.

Another potential implication for social change resulting from this study is that walk-and-

talk may be a viable alternate offering for clients that do not find traditional therapy

settings appealing or comfortable. Walk-and-talk may also be a way to engage clients

who would otherwise avoid traditional therapy because of the continued stigma

associated with it.

Theoretical Implications

No theory was generated as a result of this study; however, IPA studies may serve

as a launching point for theory generation (Reid et al., 2005; Smith et al., 2009) and

future studies. Participants in this study alluded to an increase in cognitive and emotional

benefits when physical activity and nature were combined with their talk therapy

sessions. These participants also highlighted benefits and improvements in their physical

and overall well-being. Thus, it could be postulated that the combination of physical

activity, nature exposure, and psychotherapy work synergistically for increased benefits

to well-being than incorporating these components separately. This would be an

appropriate consideration for future research.

Recommendations for Practice

Based on participant input from this study, numerous recommendations for the

practice of walk-and-talk therapy emerged. Walk-and-talk clinicians should avoid

coercing clients into participating in walk-and-talk therapy. They should also conduct a

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detailed informed consent prior to engaging in walk-and-talk covering potential risks and

benefits, as well as addressing client concerns before the onset of outdoor therapy

sessions. Therapists should respect and encourage personal agency for client preferences

related to their walk-and-talk experience including having an alternative space, including

a phone or online option, for sessions in which client does not feel like engaging in walk-

and-talk therapy. Clinicians should address issues of confidentiality and the presence of

others in the outdoor space and work collaboratively with the client on how to manage

these scenarios. Finally, therapists should assess client suitability and preference for

outdoor sessions, including assessing for severity of client issues or client’s sensitivity to

sensory stimuli they may find distracting from their therapy experience.

Conclusion

Many therapists have championed walk-and-talk therapy based on their belief in

the benefits of physical activity and exposure to natural outdoor settings, in combination

with talk therapy. This study confirmed some of these therapists’ beliefs about the

practice, as well as bringing to light some new considerations regarding the altered frame

of the practice. Walk-and-talk therapy may be a viable alternative for clinicians to add to

their therapeutic repertoire, particularly for clients who may struggle with the intensity of

sitting face-to-face in a traditional office setting. Walk-and-talk may also be a way to

normalize the experience of therapy for some and reduce the stigma associated with

seeking help for mental and emotional issues.

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Appendix A: Interview Schedule

The following interview questions are proposed for conducting a semistructured

interview in order to answer the overarching research question, “How do adult clients

experience talk therapy conducted while walking side-by-side with their therapist in an

outdoor setting?”

1. How did you decide to participate in walk-and-talk therapy instead of traditional

in-office therapy?

2. Tell me what it was like for you to participate in therapy sessions outdoors while

walking with your therapist.

The following prompts will be used as needed to elicit more detailed information

about the participants’ experience of the biopsychosocial components that shape the

phenomenon of walk-and-talk therapy.

• How did being outdoors influence your experience of your therapy sessions?

• How did walking influence your experience of your therapy sessions?

• In walk-and-talk therapy you are side-by-side with your therapist rather than

face-to-face. How did that influence your experience of your therapy

sessions?

• Tell me more about _____.

• What else do you think is important for me to know about your experience of

walk-and-talk therapy?

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Appendix B: Horizontalization Samples

Participant A Horizontalization Samples

• I was actually doing the traditional face-to-face therapy when she said she was

cutting back her office time and doing more walk and talk therapy and would I be

interested in doing that. And I said that I would, and it was the days that I could

do it.

• She was doing walk-and-talk, so it was sort of random.

• . . . my brain was moving faster with the rest of my body that was moving. It felt

more natural, less forced being outside and walking instead of just having to sit

there.

• I don’t know if it’s, like, hormonal or chemical when you’re walking around, but I

just feel like I could think more clearly as I was moving.

• It was nice to get a workout in as well. It felt good after that.

Participant B Horizontalization Samples

• My therapist invited me. She texted one day before a session. It was fairly new to

her. And she just messaged me one day before a session and said, “Do you want

to meet in the park today?” And I was like, “Oh, that’s cool.” I didn’t even know

it was a thing.

• I was a little . . . I wasn’t exactly sure how I felt about it. Like, “Is it going to be

super therapeutic?” That’s how I got introduced to it.

• I got to know that she’s always up for walking. It doesn’t matter the weather.

She’s always up for it, no matter what. She’s great, but she will also do whatever I

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want too. So, I would decide whether to do walk-and-talk depending on if I felt

like it was going to be a heavy-duty session, and if I felt like I needed to cry I

would say, “We need to be in the office today.” It didn’t always happen. I could

never predict it.

Participant C Horizontalization Samples

• I had that experience here, which was your classic, office, couch scenario, but I

didn’t feel like it was super easy for me to talk to my counselor just because it

was a kind of forced setting.

• I think that while I don’t personally agree with the stigma behind therapy, there

definitely is a stigma. And while it’s getting better, I was super nervous about

going in the first place.

• It just felt like two friends going to a park to catch up. And while our talks were

very focused it was very natural. I think meeting anyone for the first time is a

little bit awkward, so I think at first I was a little bit reserved, but it’s just because

I was still getting to know her . . . but as time went, that kind of break down

period moved and progressed much faster and it was a lot easier for me to feel

comfortable with her faster because our relationship wasn’t for me just associated

with this professional, doctor/service type thing. It was more of a way for me to

sort things out and have a debrief at the end of the week.