What is WalkinTalkinTherapy?
I have always believed in the healing powers of nature. When thinking about opening my private practice, I knew I wanted to incorporate the outdoors into the work I do. WalkinTalkinTherapy was born of this vision.
What I have found over the years is in combining the simplicity of walking outdoors with talk therapy, this approach of being active during session helps patients relax and open up quicker. Scientist have long known that a workout can temporarily boost serotonin levels and improve mood, the latest research show that combining exercise with therapy can have a deeper and more lasting effect. As I continued to research the subject I came across the articles listed below which support this.
The New Mental Health Therapy?
Sept. 1, 2006
Looking for some peace of mind that goes beyond the therapist’s couch? The solution could be found in exercise. Now, counselors are providing a new kind of mental health treatment that combines talk therapy with physical exercise that includes everything from walking and hiking to tennis and golf. Clay Cockrell, a New York City licensed social worker, has taken his therapy off the couch and into the great outdoors. “I meet you. We do our session. It’s just much more convenient,” Cockrell said. Antidepressants are taking away business from talk therapy, according to some experts. A recent study found that less than 15 percent of patients had the suggested amount of follow–up care after starting medication. So therapists have to find new ways to keep people interested in talk therapy. Cockrell thinks combining talk therapy with physical exercise might increase the number of people considering talk therapy. “I think we’re becoming a society looking for a quick fix. I go, I take my pill, and I’m better,” he said. “It doesn’t work that way.”
There’s an added bonus in walk and talk therapy — the exercise. Research has shown that even a light workout helps diminish bad moods and relieve pain. “It’s not for everyone, but for those that it works, it really, really works,” Cockrell said.
Some critics, however, say the new type of therapy is unprofessional and doesn’t protect clients’ anonymity. Cockrell, however, disagrees. “I think that it’s still a session. You’re here for 50 minutes to an hour whether we’re in an office or we’re outside walking in the park,” he said to “Good Morning America.” For the clients, exercise therapy seems to hit a lot of birds with one stone: fitness, healing, and a little fun.
He is one in a tiny pocket of mental–health practitioners who are combining physical activity and talk therapy. The methods range from strolls to more rigorous “Adventure Therapy” programs, which involve wilderness experiences like rock–climbing and camping. Atlanta psychiatrist Sheldon B. Cohen runs with his patients, while licensed counselor Geri Dube takes her clients on walks around Seattle.
But some prominent doctors are critical of the approach, saying that it can violate professional guidelines meant to establish boundaries and maintain confidentiality. Therapists have also found some real–world risks: Clay Cockrell, a New York social worker who walks with his clients, has witnessed a mugging in Central Park and an explosion during his sessions. Psychotherapist Terri Hengesh, who hikes with her patients in Northern California, has run into snakes on the trail. (If you encounter a snake while walking with your therapist, is it really just a snake?)
The alternative treatments come as mainstream therapists are under pressure, in part because of the success of drugs in treating mental illness. Patients are increasingly opting for medication over talk therapy. Nearly 15% of adults used an antidepressant at least once last year, according to pharmacy benefit manager Medco Health Solutions, up from 12% of adults in 2001. And while drugs are often meant to be used in conjunction with talk therapy, medication is serving as a substitute. A study published this month in the American Journal of Managed Care found that less than 15% of patients received the suggested level of follow–up care after starting antidepressant medication — the U.S. Food and Drug Administration recommends weekly face–to–face visits in the first four weeks. Health insurers often cover just half of the cost of mental–health treatments, leading patients to drop out.
A number of studies have documented the psychological benefits of exercise. While scientists have long known that a workout can temporarily boost serotonin levels and improve mood, the latest research shows that exercise can have a deeper and more lasting effect. One article in the American Journal of Preventive Medicine last year found a correlation between the intensity of exercise and a reduction in depression. A 2005 study published in the Journal of Neuroscience found that exercise increases the growth of neuronal brain cells, possibly elevating mood permanently. Advocates of the combined approach say that being active during the session helps patients to relax and open up, and some patients say they find it easier to talk while looking forward and walking, rather than staring the therapist in the eye.
Combining therapy with nature and activity isn’t new. In the late 1800s, Sigmund Freud walked with some of his patients through the streets of Vienna and even brought a few of them along on his vacations, says Jacques Barber, associate director of the Center for Psychotherapy Research at the University of Pennsylvania School of Medicine. In later years, Freud moved to an enclosed space to eliminate distractions. Still, up until the 1960s, when antidepressant medications became more common, people with symptoms of depression were often sent to rural retreats were they would garden, chop wood or stroll with doctors. Even today, therapy isn’t limited to offices. A behavioral therapist might take an obsessive–compulsive patient into a dirty train station to confront their worst fears, while others take clients outside, to a park bench or garden.
A Dangerous Combination
However, some warn that combining sports and therapy can be dangerous. Dr. Barber says that engaging in sports could lead to “multiple relationships” between therapist and patient. “To maintain boundaries, people have to be very cautious,” he says. “If you play tennis with them, where do you stop?”
Peter Kramer, a clinical professor of psychiatry and human behavior at Brown University and author of “Listening to Prozac,” believes that an activity like tennis can add an unwanted element of competition. If a therapist takes too much pleasure in the sport, it can be a problem, he says, “since many patients have had parents who were very competitive, or who were more interested in themselves than in their children.”
Many of the practitioners say it was an intuitive decision. Keith Johnsgard, professor of psychology at San Jose State University and author of “Conquering Anxiety and Depression Through Exercise,” started walking with his patients when he realized that he was less anxious after working out with colleagues at lunch.
Mr. Cockrell in New York hoped to expand his practice by meeting busy patients at the office for a stroll at lunch or on the way home. Now he walks with five clients a day, at $150 for 50 minutes. He recalls “a great session” when a manhole exploded in front of him and a client, forcing them to realize that “you could be zapped at any time.” Another time, Mr. Cockrell and a patient who wanted to be more assertive encountered a woman being mugged. “It was an opportunity to put this into action,” he says. “We both started yelling and the thief ran off.“
Exercise is good for the body and the mind. It may improve psychotherapy sessions, too.
By Suzanne Wright
April 11, 2008
Work is a walk in the park for Clay Cockrell. Instead of seeing patients in a traditional office setting, the Manhattan-based licensed clinical social worker practices therapy that combines exercise with psychotherapy -- mostly in Central Park and Battery Park.
"It's very similar to traditional psychotherapy," he tells WebMD, "except you are walking while you are talking about issues. I have found that bringing a little bit of movement enriches the counseling session. My clients are intrigued by the idea and are naturally drawn to being outside."
Kate Hays, PhD, is the author of Working It Out: Using Exercise in Psychotherapy and has incorporated sports psychology into her clinical practice for more than two decades. Now located in Toronto, Hays continues to explore the mind-body connection in her consulting practice, The Performing Edge, and is past president of the American Psychological Association's division of exercise and sport psychology.
Hays says she first encountered the concept of movement and therapy in the early 1980s -- reading such books as Thaddeus Kostrubala's The Joy of Running. The hypothesis is that rhythmic exercise, such as walking, can be conducive to the process of self-discovery.
Hays cites three key reasons for combining exercise and therapy:
- It encourages a patient to be more physically active for mental and physical reasons.
- It helps a patient get "unstuck" when confronting difficult issues.
- It spurs creative, deeper ways of thinking often released by mood-improving physical activity.
"Some patients may become anxious when confronting something difficult in a traditional seated, face-to-face interaction," she says. "Walking in parallel with visual distractions may allow for easier engagement."
Walk and Talk Therapy: Tapping Into Nature's Healing Power
Cathy Brooks-Fincher, a Brentwood, Tenn.-based licensed clinical social worker with 20 years of experience, has also found this to be true. An avid runner and athlete, she has observed that patients at all levels of fitness can benefit from fresh air and exercise when it comes to processing their feelings. She initially began using walk and talk therapy with teenagers who were having a hard time opening up.
"When I took them into an adjacent park, I found that patients were much more relaxed and the sessions were much more productive," she tells WebMD. "Patients have verified that looking forward rather than directly at a therapist can help them open up.
" Brooks-Fincher also praises the "healing power of nature." She says many patients consider the association of being outdoors with recreation and vacation, two very positive things that most people want to experience more.
"We have a beautiful setting in which to do this, a public park with a paved path that runs along a small river," she says. "There are turtles, deer, birds, and a horse farm; restrooms and water fountains are nice assets. Clients who try walk-and-talk often have very dramatic shifts in their thinking about relationships in their lives."
Licensed clinical social worker Carlton Kendrick, EdM, who is based in Cambridge, Mass., agrees. He got his start using exercise and therapy when working with institutionalized and incarcerated patients in the early 1970s.
"When I got people walking on the grounds, listening to cows mooing and birds singing, having to avoid a rock in the road, engaged in a multi-sensory experience, the result was the patients were much more talkative and relaxed."
Walk and Talk Breakthroughs
Movement propels people forward -- literally and figuratively.
"Something changes when people warm to this [therapy]," Kendrick says. "They come in their body armor -- their suits -- and when they change their clothing and when they see me in my sweats and sneakers, they loosen up. The literal and metaphorical ability for them to move, to experience freedom and a lessened sense of confrontation, of 'being under the microscope,' that they may predictably feel in my or anyone's office setting.
"The comfort of a patient establishing his or her own rhythm is secure," he continues. "And it's a subtle bond -- we are in sync, we are on an adventure together. Being in nature takes [the session] out of my power base and into the streets and hills. It's much more of an equal turf and provides more parity."
Hays agrees. "At any point in psychotherapy where a patient is at something of an impasse or if a patient is alienated, those are situations I would be likely to offer this as a way through whatever is going on. A patient might be able to view a situation with more clarity, more insight, and make connections which she otherwise might not be able to because of the biochemical effects of being active."
Debbie, one of Cockrell's patients, says she tried standard therapy in the past but praises the benefits of walk and talk."In my experience," she tells WebMD, "taking four walls out of the equation helped me open up and feel more comfortable. He plans the route perfectly; all I have to do is follow his lead, which allows me to get lost in my thoughts and emotions and really work it out without thinking of the ticking clock," says Debbie who asked that only her first name be used. "It allows me to open up more than I would have sitting in a room staring at someone. Also since my blood is pumping, I'm more open to new ideas, my brain is working in a different way."
Walk and Talk Therapy: Is It Right for You?
Numerous scientific studies have shown the positive effects of exercise on the brain, especially for people with depression.
Brooks-Fincher says that depressed patients often "turn a corner" when using this practice.
Additionally, anxious or grief-stricken patients are also well served by walk and talk psychotherapy. "Because grief can be so totally consuming and feel so heavy, having the counterpoint of being outdoors and accomplishing something positive for one's health can provide a sense of aliveness."
She also says that relationship conflicts are where "light bulbs really go on in terms of having a different perspective. In an outdoor setting, [patients] are more receptive to feedback from the therapist."
Kendrick agrees. "Clients who are feeling trapped in a relationship or a job, or who are pretending to be somebody they are not will feel a sense of freedom" with walk and talk therapy." Hays adds that domestic abuse patients may also benefit by "being able to frame things more positively."
Cockrell has also found walk and talk to be especially good for his male patients.
"I have a theory that men have difficulty with eye contact in the office, chair to chair, knee to knee, revealing very private and possibly painful things," he tells WebMD. "Walking side-by-side can help a man become vulnerable."
In addition, he says substance abusers can benefit from walk and talk movement.
Walk and Talk Therapy: Confidentiality Concerns
What happens if a client, wrestling with an explosive or emotional issue encounters someone they know -- perhaps a neighbor or work colleague -- during a walking psychotherapy session. Would confidentiality be compromised? How would that situation be handled to minimize embarrassment? What are the boundaries?
"Those are exactly the kinds of situations that are a therapist's responsibility to raise with the client," says Hays. "If one of us sees somebody we know, we just casually say 'hello' and keep on going. It's not explicit what's going on. In my experience it's been fine, not the slightest bit problematic."
Although it was of initial concern to Cockrell, he says, "It's just two people walking and talking; there is nothing to say this is a therapy session. If I see a group of people I recognize I can steer us in another direction. I've not had a client say it's uncomfortable."
Brooks-Fincher says occasionally she or her clients will be greeted by someone they know when in a public area. "It is something I discuss up front. It has been an interruption but not an impediment. We don't slow down and people realize we are in intense conversation."
Likewise, weather doesn't seem to be a deterrent to dedicated walk and talk patients and therapists.
"I walk with my patients 12 months a year," Cockrell says. "Once my clients have experienced walk and talk they don't want to go to the office. New Yorkers spend so much time indoors -- at home, in the office, in the subway -- it's a nice break. It's rarely so bad they can't put on an extra coat and gloves or carry an umbrella."
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