*2.8.2.1 Walk and talk*

In its most basic form a 'walk and talk' in any green space can be understood as transferring the therapist's skills to the outside environment, and conducting the session as you would inside a room, but instead, walking instead of sitting. Additionally, grounding and mindfulness exercises can be included to ensure the client is having an embodied experience and remains grounded and safe. This exercise can work well for meeting and sitting somewhere outdoors in nature (preferably somewhere that protects the client's confidentiality) and offer another option for those who may find

*Psychotherapy in Nature: Exploring an Alternative Psychotherapeutic Framework to Address… DOI: http://dx.doi.org/10.5772/intechopen.104627*

walking physically challenging. This exercise creates opportunity for an embodied experience and allows authenticity and congruence, encouraging a body-mind connection.

#### *2.8.2.2 Forest bathing*

Forest bathing derives from the Japanese practice known as Shinrin-Yoku. It was developed as a practice for physical as well as mental wellbeing. The idea is to immerse yourself in the forest surroundings by using all five senses. Similar to the walk and talk, this exercise offers opportunity for an embodied, mindful experience, encouraging body-mind connection and an authentic encounter. Sessions can include guided meditations and moments of stillness, either sitting or standing.

#### *2.8.2.3 Mindfulness*

Most agree that the definition of mindfulness is simply to pay attention to the present moment by using all five senses. In doing so, we can introspectively reconnect to our body and mind moment by moment. This offers clarity, improved cognitive function, and a reconnection between body and mind. It can consequently help to realign a congruent experience between a person's inner and outer world. Simple mindfulness exercises can be to notice the surroundings, and what you can see, hear, touch, smell, or feel. In nature, we can ask the client to notice every step they take, and how it feels when their foot is connected to the earth etc. Being mindful helps to improve mood, and lower anxiety, as well as increase emotion regulation. Mindfulness based cognitive therapy (MBCT) is a powerful tool, and fitting with the concept of combining nature interventions with room-based work. MBCT teaches the client to pay attention to their thoughts, which in turn can positively impact and change unwanted feelings and behaviours.

#### *2.8.2.4 Grounding*

Grounding exercises in nature can be as simple as hugging a tree for a few minutes, to walking barefoot (where safe to do so); or planting seeds/plants with bare hands. This direct connection to nature improves the body-mind connection, and this improves the physical and psychological state of a person. Another grounding exercise that is particularly useful when someone is having a panic attack, is to get them to turn their head and body 360 degrees, as slowly as they can, and notice everything that they can see. Some people like to say the things they notice out loud, others in the mind. If a person is highly anxious, and this interrupts a session continuously, grounding exercises can be done as often as needed.

#### *2.8.2.5 Meditation-guided body scan*

For a highly stressed, anxious, or dissociated person to have an embodied experience in nature, a powerful exercise to carry out is a body-scan meditation. It is a great exercise for moving a person away from over-reliance on cognitive function and processes, and into their body. To carry this out, the practitioner invites the client to close their eyes, or focus on something still in the distance. Relaxed, long breaths in and out are encouraged, directing the client to breath into the stomach space, as opposed to the chest. The practitioner then leads the client to mindfully notice each and every

part of their body, from head, to arms, to stomach to toes. Throughout this process, it is common for people to struggle with intrusive thoughts, distraction etc. The practitioner must encourage the mindful practice of noticing these thoughts or feelings, and bring the focus back to the body or the breath each time it occurs. At the end of the scan, the practitioner can ask the client what it is like to be inside their body, whether it is the same or different to usual, etc. They then guide the client to bring awareness back into their surroundings by noticing any sounds or sensations they can feel or hear, and to gradually open their eyes. The practitioner can then explore with the client if they noticed anything during the body scan. This exercise can be carried out at the beginning, and repeated by the practitioner or the client as many times as is needed throughout the session if beneficial. Please note that this exercise may not be suitable for highly traumatised individuals, early on in their process, before they have reached a period of stabilisation. This is due to the levels of dissociation being so high, and at this stage of a client's process, leading them into their bodies can be extremely re-traumatising.

#### *2.8.2.6 Mandala creation*

The term 'mandala' derives from Sanskrit and translates as 'circle'. It is a creation of geometric patterns, often used to depict elements of the universe, incorporated with Buddhist and Hindu teachings. In the nature therapy context, mandalas can be created as a form of art using natural elements. The client can be directed to collect flowers, leaves, and different natural elements using a variety of textures and colours. To start with, they would create one large circle on the ground with leaves for example, followed by smaller layers inside. This can be delivered as both a mindful and grounding exercise, and the mandala can be used to represent a dream, the client's life, self-image, as an ending exercise to represent their journey of therapy, etc.

#### *2.8.2.7 Bringing nature therapy inside the therapy room*

If you would like to create a natural environment inside the therapy room, you can bring in plants, flowers, rocks, sand, water, fish etc. You can ask the client to connect to the nature through meditation, or breathing it in, or indeed to touch or feel the natural elements. Listening to nature sounds can also promote relaxation, and this can be used as a grounding or mindful exercise. Another exercise that doubles as both mindful and grounding, is planting seeds/flowers. This can also be a metaphor for the client's new journey into therapy. Using sand to create art, or simply to feel and notice the texture can be a useful tool to encourage an embodied experience. Asking the client to hold a rock or form of nature, can work in combining a cognitive therapy intervention with nature therapy. Feeding the fish in the tank can open up dialogue for the meanings of care-taking, encourage connection with nature, and thus with self. Exercises observing the fish can also be very beneficial. A mandala can be created on paper using sand, and other natural elements that the therapist can collect prior to the session.

#### **2.9 Ethical considerations for nature therapy**

There are a multitude of questions that the basic ethical framework poses, and many referral agents will ask, when considering working with clients in outdoor

*Psychotherapy in Nature: Exploring an Alternative Psychotherapeutic Framework to Address… DOI: http://dx.doi.org/10.5772/intechopen.104627*

spaces. It is crucial to create policies and procedures in order to address these. Below are 10 examples of questions and areas to be thinking about if you would like to work with clients in nature:


#### *2.9.1 Addressing diversity and inclusion in nature therapy*

It could be argued that there is a slight ethical dilemma in defining who can/ cannot participate in nature therapy when you are using a client-led model or approach, as ultimately, we aim to offer the client full autonomy over their

decisions regarding how they participate in therapeutic activities. That said, psychotherapeutic frameworks must be based on safety and managing risk, and the importance of creating a boundaried framework for the service, are what fundamentally help to maintain client safety and manage risk, in order to provide a safe space for effective therapy to take place.

The University of Exeter in the UK have created a handbook [10] for services to refer to when working with service users in a range of therapeutic nature settings. They suggest that the following be taken into consideration when going through the referral and or screening stage:

Ref. [10] suggests that the most important element to building trust with service users or referral agents for nature therapy are: honest and accurate information sharing of the site description. It could therefore be suggested that this falls in line with a client-led model due to the transparency and level of openness in information sharing, which fully informs the client/care giver, and allows them to make an autonomous decision on whether they feel the nature therapy is suitable or safe for them. That said, it should also be taken into consideration the vulnerability of each individual client and their capacity to make decisions safely, as well as a person's lack of experience engaging in a nature therapy session, and the therapist's knowledge of this.

Aside to the general areas mentioned in **Table 1**, during the referral process it could be argued that other considerations should be made for socio-economic and ethnicity factors, that may affect a person's desire or reluctancy to engage in nature therapy. Ref. [11] found that the way in which nature is generally used by different ethnic groups can differ significantly, and may therefore impact their overall experience of nature therapy, and consequently its effectiveness. Evidence suggests that there is a correlation between a person's desire for nature and the effectiveness of nature therapy and vice versa. The research found that in some cultures, the association between past generational trauma and hardship can influence cultural and ethnic attitudes towards nature [10, 11]. It may therefore be a criterion to take into consideration at the initial screening, and consideration be taken for whether this type of therapy would be suitable or indeed damaging to the client, or whether this challenge could be positively overcome.

Accessibility to services is a key area for consideration in this topic. When reflecting on socio-economic factors, it is well understood that psychotherapy has long been framed as being for the private sector, or those who can afford the luxury. This may


#### **Table 1.**

*Referral screening considerations: information taken from 'Nature on Prescription Handbook' [10].*
