**2. Characteristics of traditional psychotherapy frameworks**

Generally, most traditional psychotherapeutic frameworks are based on the following: initial engagement in an assessment or screening with the service to determine whether the service/practitioner is right for them and their struggles; agreeing a set amount of sessions relevant to budget or necessity for improvement, determined at assessment stage, e.g. time-limited (perhaps 6–20 sessions) or open- ended work (as many sessions as required, which may be years); thereafter, client and therapist working within a room-based setting that usually has two comfortable chairs and engaging in talking therapy; on average, meeting once or twice weekly for 50–60 min; in an ideal situation, upon completion of the work, agreeing and planning on working towards a suitable and safe ending session.

It must be acknowledged that there are of course variations to the above, but in general, that is what a traditional framework depicts. Along with the theory briefly mentioned above, the common features of the psychotherapy framework have changed very little since the 1950's, which understandably, in our evolving society, leads us to notice where this framework may not work for certain individuals, groups or presentations today.

One of the most salient research areas of psychotherapy, is the therapeutic relationship and its positive correlation with effectiveness. It has been argued that for this relationship to have a meaningful or positive impact on the therapeutic experience of the client, there must be more than one session. However, it is also evidenced that Roger's core conditions alone impact the effectiveness of psychotherapy. Consequently, it could be suggested that there is a platform for an alternative framework in the form of a single, one-off session, so long as the core conditions are present.

#### **2.1 Single session psychotherapy**

Single session therapy (SST) is not a new concept. In Ref. [2] Dryden documents that both Freud and Adler had used a single session approach in the late

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

1800's and early twentieth century. Over the last two centuries, it could be understood that its use evolved out of a common experience a lot of therapist's encounter; which is that often clients will only ever attend one session. It can be for a number of reasons, but not least of all recognising they are not ready to engage in ongoing therapy sessions. As a consequence, Moshe Talmon published work on the 'effect of the first (and often only) therapeutic encounter' which opened up opportunity to explore how a single session could be used to maximum benefit, whilst also considering the evidence base for distinct features of a psychotherapy framework, such as a pre-assessment session, establishing and utilising the therapeutic alliance, goal setting, therapeutic process, and a safe, pre-planned ending. One of the contraindications of SST is the suitability or effectiveness of a single session for certain presentations, such as PTSD or attachment disorders. That said, there are also benefits that may address downfalls of a traditional framework, understanding that not one size fits all. The most obvious benefit of SST is that it allows the client autonomy to choose as and when they want to engage in a therapeutic encounter; and additionally, an affordable and manageable way of accessing therapy without time or financial constraints. Furthermore, as evidence suggests, SST is effective, despite the assumptions traditional thinkers may purport. That said, it is important to note that SST is not a modality in itself, but more a way of working that can be adapted and used alongside other existing frameworks. As will be discussed further in this chapter, SST lends itself to complimenting a nature therapy framework.

#### **2.2 Nature therapy as an alternative intervention**

Nature therapy, also known as ecotherapy or nature assisted psychotherapy, is driven by a social constructivist worldview. It takes the position of understanding that we are not separate to the environment or other systems inside us or around us. For example, our internal biological system is not separate to our neurological system; and we are not separate from the functions of our external work place, families and relationships, or indeed the processes and systems of nature. In understanding that we are not separate from our environment, nature therapy provides the opportunity to explore our relationship with nature, and the meanings that it may have as a parallel to the relationship we have with ourselves.

When referring to nature within this chapter, it will be relating to the outdoors in any form of green space; beach, forest, garden, water, etc. Furthermore, as will be discussed later on, whilst nature is typically found outdoors, working in a nature therapy framework can also include bringing nature indoors, or interacting with it inside, for example: listening to nature sounds; bringing plants/planting inside; working with sand; holding a rock or a leaf in your hand.

Nature therapy can take a wide variety of contexts and approaches, including horticultural and group projects, or sitting on a beach and talking with the therapist. As the area is so broad, for the purpose of this chapter, nature therapy will be referred to in the context of a psychotherapeutic framework, as opposed to social/community experiences or projects, and will include both the outdoor and indoor setting. Furthermore, it is important to note that there are currently no advanced or singular, evidence-based nature psychotherapy frameworks, and so this too, can be thought of like SST, in that it is an approach rather than a modality that can be used and developed alongside existing frameworks.

#### **2.3 Limitations to traditional room-based, talking therapy frameworks**

General presentations such as anxiety and depression can be easily and effectively addressed within the therapy room. The therapy room can feel like a safe and containing space to many individuals, couples, families, and groups. That said, even in these instances, depending on age and gender, a barrier to starting this type of therapy may be stigma and managing to engage with the service in the first place. For example, there is plentiful research literature that supports the concept that men, in particular are less likely to engage in traditional room-based psychotherapy, as well as young people, due to societal judgements and pathologizing attitudes that suggest 'you may be mad' or 'weak' if you are having counselling or psychotherapy. Organising and attending an appointment outdoors in nature at the beach, forest, or botanical garden can remove the potential and fundamental challenge of overall and initial engagement relating to stigma, and often presents as less formal and therefore not intimidating and clinical.

In thinking about the types of difficulties clients might face and where roombased settings may not work or indeed be suitable for the client, post-traumatic stress disorder (PTSD) or psychological trauma of any type is a great example. When a person experiences trauma, whether it is a one-off event or prolonged experience, afterwards, it often leaves the body in what we would call a hyper-vigilant state: the brain is telling the nervous system to constantly be ready for oncoming threats, and as such, similar or other environmental cues can trigger the brain into the primal survival response of fight, flight or freeze. In my clinical experience, it is most common that individuals seeking therapy for trauma related difficulties can find being shut in a small room with another person very triggering. By that, I mean their nervous system can perceive that setting as a threat. Often the notion of being trapped inside a room and not being able to 'flee' (flight) when triggered is a barrier for someone of this presentation engaging in this type of therapy at all.

Continuing with the example of PTSD/trauma, we can also discuss the other two responses (fight and freeze) the brain may instruct when triggered, which are not just limited to a trauma survivor, but can be present in a number of different presentations such as autism spectrum disorders (ASD), generalised anxiety, etc.; in fact, any of us, at any moment could experience this during therapeutic processing. In Ref. [3] I describe in more detail the cognitive processes involved, and the nuances of cognitive/top-down therapies versus body/'bottom-up' therapies. When we experience a highly stressful or traumatic event, functioning in several areas of the brain is disrupted. Additionally, part of our brain called Broca's area, responsible for retrieving verbal memory will shut down. Its function is to enhance our survival in a potentially unbearable physical or psychological painful event(s). What this means in relation to talking therapy, is that when we try to recall traumatic memories, Broca's area will shut down in the present moment, leading to the client freezing in the room, unable to speak or move. This can disarm an unexperienced therapist, and re-traumatise the client, leaving both parties in a fairly powerless and hopeless position.

In considering the fight response and the relevance to working with clients in a room-based setting, similar can be said to the previous discussions. When attempting to process past memories, or indeed present experiences, particularly when clients are in a state of hyper-vigilance, there is just as much chance that their brain may respond with a 'fight' response. When shut in a room, this can be dangerous and traumatising for both the client and therapist, not least of all that the room can be a trigger in itself. If the therapist has experienced trauma themselves, and becomes triggered

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

from a severe anger response, it could be an extremely dangerous situation if neither can escape. Whilst general safety measures are taught during therapy training for managing high risk situations, such as to sit in the chair nearest the door, and have a panic alarm nearby, if the freeze response occurs for the therapist in a highly charged situation, these safeguarding parameters become void.

The limited examples I have provided in this section are enough of an argument to consider the need for alternative settings or modalities, and not least of all in relation to the importance of the type of processing that is required for individuals in many presentation groups. As briefly mentioned above, there are times and situations where an individual is unable to attend sessions in a room, and more specifically, where there is a need for the type of processing to be non-verbal, or 'bottom-up' as opposed to 'top-down'.

Top-down processing can be understood as cognitive-based talking therapy interventions, which rely on functions of memory and attention bias. When considering the information presented above in regards to Broca's area, this form of processing poses a problem and indicates a need for an alternative intervention [3]. Furthermore, in considering other presentations or individuals who might struggle to engage in a talking therapy setting; executive functioning and attention bias are evidenced as key areas that are fundamental for cognitive or talking therapies to work. Consequently, for those with PTSD, ASD or similar presentations, an alternative, effective solution is needed.

#### **2.4 The medical versus biopsychosocial model**

When considering our human existence and our own sense of self, we are forced to consider our own world views on whether we feel our minds are separate to our bodies, or whether they are indeed interconnected as one. Cartesian theory suggests that our mind functioning is separate to our body functioning, and importantly to note, fits hand in hand with the medical model, adopted by national health services, medical insurance companies, the pharmaceutical industry, and medical practitioners today. The medical model attempts to locate within the body, individual ailments or disease; also known as pathologising. This way of understanding our human existence leaves little room to consider the environments we exist in, such as family, work, school etc., and the influences these play on our well-being; socioeconomic factors influencing diet, or workplace factors influencing stress for example.

In considering the topic of stress; it is a well-documented concept that stress caused from external environments has a strong relationship with physical ailments and disease. Let us consider I have a headache: I can either take a pain killer (medical model approach) or I can evaluate whether there's something in my environment that is causing this, or perhaps how much water I have had to drink, or how much fresh air or exercise I've had. The latter way of considering the headache would be fitting with the biopsychosocial model, which differs to the medical model by taking into consideration the connection between body and mind, and takes the view that our bodily systems are all interrelated, and in relation(ship) with our external environments.

It can therefore be argued that talking/cognitive/top-down therapies are mostly based on the medical model approach, with exceptions such as sensorimotor and body psychotherapies, which may be conducted in a room-based setting alongside talking therapy. This poses several ethical questions about accessibility, suitability, inclusivity, working with diversity, and highlights the need for alternative interventions or approaches to traditional frameworks. Furthermore, therapists working

within a room-based setting may feel limited to those confines, and, restricted therefore in their interventions in regards to responding to current global issues. Interventions carried out in a room-based setting, may encourage use of techniques, such as issues of anxiety raised about the client's external situation, as being a platform for exploration of past events (e.g., CBT/Psychodynamic), placing the issue inside the individual, thus taking an individualistic, pathologising position, which could potentially be harmful to the client.

#### **2.5 The importance of mind-body connection and bottom-up processing**

As humans, we have evolved to move away from using our bodies as sensing tools in regards to primal safety, non-verbal communication, illness, and so on. Over time, we have formed a reliance on language as our primal form of communication; a reliance on cognitive processes to make sense of situations, including physical illness; and become increasingly dissociated and desensitised from our bodies. It is of my opinion that the over-reliance on these cognitive functions forms an extensive part of mental distress/disorders seen today. Take depression for example: clinical depression diagnosis is generally treated with medication and cognitive behavioural talking therapy, and commonly understood by society as being negative, or someone having something wrong with them (pathologising) by experiencing low mood or suicidal thoughts or feelings, thus fitting into the medical model appraisal.

The umbrella term of depression however, can be thought of very differently, as a straightforward, animalistic behaviour that is shared across the mammalian life span. In understanding it in this way, we can consider its purpose as being there to communicate when we need to hibernate, withdraw from our environment, rest, or process a difficult, stressful, or upsetting situation. This perspective would fall into the biopsychosocial model of understanding.

These examples start to paint a picture of how society has been conditioned to desensitise, and dissociate from primal, body-mind functions, and instead, adopted a shaming culture in which pathologising labels are used to diagnose one another. Following that, it is then expected that if you are not functioning in a typical 9–5 job; coping with the kids; your elderly parents; your kid's school projects, and whatever else life throws at you, that there is something wrong with you.

For all the reasons named above, it is glaringly obvious that through human evolution, we have lost touch with our body-mind connection, and in doing so, the essence of our true selves and external environments.

#### **2.6 Human evolution: adjoining the inner and outer worlds**

According to Psych Central, 'human beings have been talking about their inner lives and challenges with one another therapeutically for centuries' [4]. Our inner world can be understood as our thoughts, feelings, emotions, beliefs etc., whilst our outer world are external factors making up and relating to our physical existence, such as material objects. It can be slightly more complex than this, as the outer world is also what we display and communicate to others. It has been said that our outer worlds reflect our inner worlds, but this opens up a curious topic for discussion. Does what we feel inside always match what we display to others in our outer world, and does it always align with the situation or setting we are in? For example: Susan's sister is about to have life threatening surgery after a car accident. She is concerned and distressed, but has a presentation to deliver at work in order to secure an important

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

contract; she is likely to display a professional, jolly, composed, disposition to her work colleagues on the outside, which does not reflect her true, inner world at that time. This process is likely a form of dissociation, which is where the brain has the ability to detach from our feelings and bodily sensations, including distress and physical pain. It is an inherent, primal mechanism which serves to protect us during highly stressful or traumatic events in order to survive.

Today, within our high-pressured culture, there are many situations similar to Susan's where society dictates a set of norms or behaviours that are acceptable to display in public or as part of our outer world. One particular example comes to mind when considering a shared human, inner world experience, which is the feeling and expression of anger. Anger is one of Darwin's six basic emotions which he hypothesises are shared across the human and animal life span [5]. Anger is a core emotion that we all experience as humans. It is another primal, survival response that serves to protect us when we are in danger, and ties in with the notion of fight instead of flight or freeze. Within society, healthy expressions of anger are not acceptable in many settings or situations, and in this case, there would be a need to not display our true, outer world. We are taught very early on as children that expressing anger is not allowed, and that it is bad, as opposed to emotions such as happiness, surprise, etc. Bearing in mind anger also serves as a primal safety mechanism (fight/flight), what do we then learn to do when we are in situations where we feel angry? As children, most of us would've found some form of dissociative mechanism that allowed us to detach from feeling angry, in order to display an incongruent reflection of our inner world to our outer world, which begs the question as to what else we dissociate from, and how normal this has become as part of human evolution.

The importance of living congruently between our inner and outer worlds is not something that is spoken about much outside the psychotherapy industry, nor is it particularly acknowledged, which suggests that incongruence in our lived experience has become a societal norm. My clinical experience both directly with clients, and indirectly through supervising practitioner's work with their clients, shows a salient theme in regards to the societal pressure of holding it all together, and "*keeping up with the 'Jones*'", displaying an incongruent or false outer self. Children in particular, are increasingly suicidal from the emotional overwhelm, and pressure to cope and maintain this perfect image, which ultimately results in switching off the bodily, emotional, felt-sense and over using cognitive processes to try and fake. This leads to dangerous levels of dissociation and is currently creating a crisis that is unmanageable for national health services. As traditional talking therapy frameworks are in crisis, I postulate whether an alternative framework such as SST or indeed nature therapy interventions would be beneficial in attempting to manage this.

#### **2.7 The importance of a congruent, environmental framework for therapy**

Speaking very generally and across a broad spectrum of presentations, in my clinical experience, a lot of clients seek therapy due to a form of distress becoming intolerable or unbearable, resulting in difficulty experiencing emotions and the overwhelm these can cause. This can be because of coping strategies developed as a child to survive in the family environment; stress or trauma due to a single or prolonged experience; illness and so on. What I have experienced as a theme shared amongst these clients, are that their inner world experience is not able to align with their outer world, lived-experience; not dissimilar to Roger's theory that clients seek therapy in a state of incongruence, that there is a conflict that they are seeking help to resolve. In

exploring some psychological symptoms that might conceptualise these difficulties further, let us consider an example: Mark is a successful, driven, businessman who plays golf on the weekend with his friends. He is the life and soul of the party, but at home, he is quiet and introverted, and has started drinking a bottle of vodka each night, which is impacting his family/home life. He has contacted the psychotherapy practice to seek help as he is afraid of losing his family due to his drinking. I have given this example as I believe that even without psychotherapeutic training, we can see that there are two lived experiences for Mark, which we might infer as relating to both a congruent inner world reflection (the home experience of drinking etc.) and an incongruent inner world reflection (appearing to function as successful, life and fun of the party). The distress the conflict is causing Mark is what has led him to seek therapy.

Our work with Mark might involve exploring his inner world, and finding out if there is an underlying reason or process that is leading to the conflict between his inner and outer worlds, causing the intolerable distress that leads to the coping strategy of drinking alcohol/numbing, and feeling depressed. Whilst we could go a number of ways and much deeper with Mark's psychological formulation, this section is about exploring the inner and outer worlds of our lived experience, and what that might look like. Mark's example is sadly not uncommon, and is a classic illustration of trying to function in a society that demands a certain level of functioning, including what emotions and feelings are acceptable to show to the outside world. As a result, Mark is left with a distressful, incongruent existence.

#### **2.8 Nature therapy and its applications**

Whilst the same could be said for traditional room-based settings in some areas; a core strength of nature therapy is the broad range of settings and activities that can be offered to different groups of people with varying abilities and disabilities; those who are non-verbal and or experience difficulty in speaking, including language differences; and ethnic and socio-economic factors. It has been highlighted in previous discussions in this chapter, that room-based settings pose ethical compromises for inclusivity and working with diversity; nature therapy is able to lend itself to working with a broad range of presentations including trauma/PTSD, ASD etc.

Nature offers a congruent, non-judgmental space for people to recover. These attributes are parallel components to the humanistic conditions that Rogers specifies as necessary for therapy to be effective. In nature, people feel they can be their true selves, and consequently can feel 'at one' or connected to nature, regaining the natural connection to their body, emotions and feelings. This is not only experienced as a relief, but often an opportunity to process and be with feelings that have been avoided or numbed for long periods of time. When combining nature with traditional frameworks of psychotherapy, there is something that is immediately shared in an experiential way between the therapist and client in comparison to a room-based setting. We have all experienced being in or around nature at some point in our lives, and according to existing literature, we will have had at least one positive experience in doing so. It could therefore be suggested that the nature element has a positive influence on the therapeutic relationship, which, as Roger's first postulated; is the core of successful therapeutic encounters. In the same vein, our own relationship with nature encourages something phenomenologically different to emerge, in comparison to what might be experienced in a room-based setting, where, without nature, an incongruent self can still be present. Consequently, nature therapy alongside even an

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

SST session is likely to be a positive substitute for traditional room-based frameworks when considering this aspect. When combining nature therapy with SST, accessibility in terms of affordability and time commitment, supporting an autonomous, clientled service, are offered.

Allowing a natural space to connect to the body within therapy sessions can lead to processing of feelings, emotions, and memories that are stored in the body. Van der Kolk's extensive research suggests that body processing is required in order to work with trauma, in particular which can lay dormant in the body for years [6]. Additionally, other neuropsychological research has taught us, that rather than pushing away or ignoring and numbing thoughts and feelings, and instead taking time to feel and experience them, actually leads to positive processing and being able to move on and detach from unhealthy patterns [7]. In some cases, solely relying on talking therapy in a room-based setting, can mean that clients are unable to move away from repetitive, intrusive and overwhelming thoughts and feelings, and get stuck on a loop through rumination. We could be the best psychotherapy practitioner in the world, delivering the perfect intervention, however, it is clear that as mankind has evolved, in a lot of cases, we require something more than talent and traditional psychotherapeutic frameworks in order to address complex dissociative and embodied issues.

#### *2.8.1 Benefits of nature therapy*

The direct physical and mental health benefits experienced from nature have long been documented in scientific studies, as well as qualitative measures that report client's verbal accounts of their experiences in nature. Since the global pandemic occurred in 2020, salience of people recognising the importance of connecting to nature for their mental as well as physical wellbeing by gravitating to natural spaces, has been well documented. Bringing nature indoors, spending more time in the garden, and travelling to green or outdoor spaces have become increasingly popular as people experience the benefits of nature to their physical and mental wellbeing.

Nature therapy is diverse in its applications, as not only can practitioners work with clients outside in a broad range of settings, such as the beach, forest, countryside, and garden; it is also possible to experience the benefits of nature inside the room. The latter lends itself to ensuring inclusivity and all corners of the population are able to be reached, no matter what their psychographic or demographic. Including nature within the room-based setting can be achieved by bringing natural elements such as sand, plants, and water into the surroundings to create a natural environment inside. These elements can also be used through other senses such as touch (sand or plants), smell (plants with perfume/strong scents), or sound (running water, rain, birds and wildlife sounds). Working in this way offers a platform for mind-body connection, grounding and working in an embodied way, which research literature suggests is necessary, particularly in considering the prevalence of dissociation and internal conflict which can be argued, is causing a lot of mental illness and dis-ease. Once again, nature therapy can lend itself to working well alongside other therapeutic modalities, which offers a broad and diverse way of working with many presentations. Importantly, this means that the issues discussed previously surrounding disconnection to the body, and reliance on cognitive processes as an intervention, can be re-evaluated and combined with a somatic, nature approach.

Working in nature also addresses societal challenges relating to stigma in accessing psychological services. Attending a session in a green space is far more appealing to those with pre-conceived concepts of the negative connotations surrounding

psychotherapy, and consequently makes nature therapy accessible to large demographics of people who may not ordinarily seek help. On an organisational level, this can boost engagement rates for services, and improve service level outcomes. The physical and psychological benefits of spending time in nature have been reported for centuries. There is a large body of research that has documented the following benefits, specifically from engaging in nature assisted psychotherapy [8, 9]:

