Therapists, patients embrace outdoor therapy in Covid-19 pandemic

Mental health therapist Allison Page (far right) of Park City, Utah, shown with Meryl Sonan (far left) and Mark Lehman (center), holds Trailtalk sessions with patients in nature.

(CNN)Therapy looks a lot different these days for Alexandra Talty.

Before the Covid-19 pandemic, the Southampton, New York-based writer attended a few sessions with different therapists in person. Once the pandemic hit, however, she decided she didn't want to be inside a confined space with someone who could possibly be a vector for the virus.
So Talty improvised, and for a group session with another family member she asked to meet with a new therapist in the therapist's backyard.
    The three wore masks until they sat, then took them off. They all sat a minimum of 6 feet apart. Save for the therapist's dog, which periodically yipped and yapped at Talty's feet, the experience was typical — Talty and her family member shared feelings, answered questions and did a whole lot of reflecting. Everything just unfolded outside.
      "Outdoor therapy is a great alternative for people who wouldn't feel comfortable going into an office right now," Talty, 32, said. "It's definitely something I would do again."
        Talty isn't the only person seeking out this kind of therapy these days. As the pandemic rages on and public health officials advise against sessions indoors, psychologists and licensed marriage and family therapists are embracing alternatives to traditional forms of therapy.
        Most have turned to teletherapy, which is essentially therapy over a Zoom-like interface that has been secured to comply with requirements established by HIPAA, or the Health Insurance Portability and Accountability Act. Others, however, are embracing the great outdoors, either by moving historically couch-bound sessions into a space where air flows freely or by building sessions around movement in nature.

          Bringing the inside out

          The most common form of outdoor therapy looks like what Talty experienced: traditional talk therapy sessions held in a yard or on a patio, balcony or roof.
          These experiences are similar to pre-Covid therapy; seated far enough apart from each other, patients and therapists can remove their face coverings and focus on psychological healing instead of worrying about potential risks in transmitting virus.
          Tatyana Kholodkov, a psychologist in Durham, North Carolina, said the setup also enables therapists to observe facial expressions the same way they would in a regular indoor session — an important tool for therapists to get at how a patient might be feeling.
          "It is difficult to do therapy with face masks," said Kholodkov, whose private wellness practice is dubbed Project YES. "There is a lot of information that gets lost when you can't see someone's entire face."
          Still, there are potential pitfalls to this approach.
          First, of course, is privacy — if sessions are unfolding outside, there's always a possibility that passersby might hear what's being said, which could make patients more reticent to open up. With unpredictable variables such as construction and animals, Kholodkov said, outdoor sessions also can threaten the controlled environment that therapists work so hard to cultivate in their offices.
          Another challenge: the elements. Rain or snow would force a therapist to reschedule, and Talty noted that she had to rebook her appointment because the original session was slated to take place on a blazing hot day.

          Walking and talking

          Other forms of outdoor therapy revolve around nature completely. Dubbed eco-therapy, this practice involves sessions that unfold in parks, forests, beaches and other open spaces.
          Among psychotherapy circles, this approach is nothing new — it's a natural extension of ongoing research investigating the extent to which being in nature helps reduce levels of cortisol, a hormone triggered by stress.
          Eco-therapy can also include forest bathing, which has been popular in Japan for centuries, and has been proven to boost the immune system and reduce anxiety.
          In the United States, eco-therapists practice eco-therapy in a variety of ways. Allison Page, a mental health therapist in Park City, Utah, has built her entire practice around meeting patients at trailheads and holding sessions in the wild. She calls it Trailtalk, and she likens sessions to emotional tune-ups for active individuals.
          "Just being in the sun and moving your body a little bit will decrease the emotional intensity of a situation, and then you can put your thinking cap on," said Page, a nurse practitioner who launched Trailtalk in the fall of 2010. "That helps get you some clarity. With that, you can figure things out."
          Page said her sessions can last anywhere from an hour to a half a day. She also offers intensive sessions — "theracations" — that amount to 10 hours of tune-ups over the course of four or five days.
          If a patient is feeling particularly vulnerable or would rather not be outside, Page can conduct the session in a Sprinter van she's tricked out like an office. In these instances, the patient sits inside the van and Page sits outside so her patients aren't sharing the same space.

          Connecting with nature

          Near San Francisco, licensed marriage and family therapist Dave Talamo has been known to take a similar walk-and-talk approach. Talamo also prides himself on a different type of eco-therapy — something that could be called a "walk-and-sit" or "walk-and-pause" approach.
          With this, Talamo will meet a patient at a trailhead and walk until they find a calm and secluded spot for the rest of the session to unfold.
          Sometimes the spot might be a deserted meadow; other times it might be atop a bluff overlooking the ocean. Talamo noted it may or may not be a spot that others find remarkable.
          During a recent session, he chose to meet a patient who was suffering from anxiety and depression at a redwood grove near the patient's home. The two stopped near the base of a tree, and the patient began ranting about how adrift he felt during the pandemic. Talamo stopped him and had the young man lean back to feel the support of a tree that has endured for many human lifetimes.
          In another session, Talamo said a patient was having trouble expressing himself at precisely the same moment that a crow flew over and started vocalizing loudly.
          The crow's ability to "speak" helped the patient unlock thoughts and put them into words.
          "Sometimes we need these connections to nature, that reminder that as uncertain as things are right now, it will be OK," said Talamo, who is based in San Rafael, California. "Those simple experiences can mean more than any back-and-forth we might have sitting on a couch."

          Dangers of eco-therapy

          While it does offer benefits, this type of therapy isn't all rainbows and unicorns. Lezlie Scaliatine, a clinical psychologist and certified eco-therapist in Santa Rosa, California, said there are several considerations that therapists must address before they begin seeing patients outside.
          For starters, Scaliatine said therapists must carry a different level of liability for outdoor sessions than they do for sessions that unfold indoors, because there are potential risks. Specifically, she noted, therapists should check to make sure their malpractice insurance covers outdoor sessions.
          Scaliatine added that while taking patients outside into nature is a good treatment approach, therapists should have basic skills around safety.
          "You really should know first aid and CPR, in the event that something were to happen," Scaliatine said. "What do you do if your client gets stung by a bee or steps in poison oak? You definitely want to be prepared."
          Page agreed, adding that outdoor therapy is not a panacea but instead another tool.
          Specifically, she noted that people with certain personality types may prefer a therapeutic experience delivered through a computer screen, and that therapists must determine what works best for whom.
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            "Just as there are going to be therapists who maybe wouldn't or couldn't embrace (outdoor therapy), there also are going to be patients who aren't going to like it either," she said.
            "The model works for extroverts, kinesthetic learners (who need to move) and people who need people at a time like this. For introverts and individuals who don't need as much of a connection, teletherapy might work just fine."