Beyond relationship? The power of therapy outdoors

The relationship between client and therapist is considered by many to be the single most important factor in successful therapy (Loewenthal, 2014). But what happens to that relationship when the therapy takes place outdoors? If you haven’t experienced therapy outdoors, you might wonder why it would make any difference to the therapeutic relationship. Isn’t it just like conventional therapy, but outdoors?

The short answer is, it depends. A few outdoor therapists strive to control the impact of the immediate environment, but most engage with it, often finding that nature becomes a kind of co-therapist. When nature enters into the therapeutic relationship, things get interesting! The client begins to form a relationship with the natural environment as much as with the therapist. The therapist is no longer “the professional with the answers and advice”, but instead becomes an “expert at facilitating therapeutic conversations” (Jordan & Marshall, 2010).

Ecotherapist Martin Jordan suggested that when we work outdoors “the myth that the self is somehow separate from nature becomes exposed as the fallacy it is” (Jordan, 2009). This complicates our understanding of the relationship between therapist and client even more. Once again – as so often in this blog – the question arises of where ‘self’ ends and the ‘other’ begins. But if the ‘self’ becomes “entirely entangled with the Other”, we might “risk losing the difference and thus any possibility of relationship” (Harris, 2013b).

David Key, an ecotherapist I interviewed for my MSc research, brings these questions to crisis point. David said:

“What actually happens when people go out into wild places, the thing that’s therapeutic, is something … I don’t know, it feels like it almost isn’t about relationships, it’s almost a Becoming […] that actually goes beyond relationship. […] Relationship is the process, not the product”.

This extract illustrates what I most like about this interview: you can hear David working with complex ideas and trying to force language to express something that refuses to be named. His ideas seemed to evolve as we spoke. David rhetorically asked “How do we as human beings even conceptualise the therapeutic relationship that the land or the sea offer us?” We can’t, but the attempt to do so is hugely illuminating.

The full interview was published in Self & Society: An International Journal for Humanistic Psychology (2015). The article is entitled “What impact does working outdoors have on the therapeutic relationship? An interview with ecotherapist David Key

Wired to survive?

According to evolutionary neuroscience we’re not wired to be happy or content but simply to survive. It’s a new science, so such judgements are subject to review, but it certainly seems that our bodymind system easily becomes dysfunctional in modern industrial societies.

Paul Gilbert is a clinical psychologist and developed a new therapeutic approach called ‘compassion focused therapy’ (CFT). Paul has identified three basic bodymind systems; one is focused on potential threats, another on finding resources, and the third on calm contentment & soothing. When the threat system is active our attention becomes like velcro for danger signs and teflon non-stick for anything positive: If you’re on alert for wolves then the fact that the moon looks fabulous is pretty irrelevant! Short-term that’s fine and once danger has passed we naturally shift to either the search and reward mode or the calm contentment system. As long as there’s a cycle between these three systems, we’re fine.

Adapted from Gilbert, 2019

Because the threat system has survival value it can override the other two and it’s activated whenever there’s a perceived danger. The threat system works on a ‘better safe than sorry’ basis so will trigger whenever we feel that a situation isn’t safe. Many people live in situations which don’t feel safe; low income, precarious or stressful work, discrimination, difficult relationships or just keeping abreast of the news. That means that the threat system is often over-active and many people don’t spend enough time in the regenerative contentment & soothing system.

Compassion focused therapy draws heavily on mindfulness to help people learn to rebalance themselves. By becoming mindful of when we’re stuck in the anxiety provoking threat system, we can learn to shift into calm contentment. Self compassion is hugely helpful in this, and though we all have compassion, we may not practice it much. In our culture it can be seen as a sign of weakness or a distraction from the busyness of our lives. But in fact compassion is a form of courage that inspires us to act. With practice we can develop more compassion for ourselves and others, healing within and making the world a better place in the process.

It’s worth noting that mindfulness is the key strategy in CFT. Mindfulness, like so many of the other approaches to alleviating mental distress, is an embodied pathway of connection. If we really are wired to survive, perhaps early humans developed the embodied pathways of connection as a route to a deeper thriving? Practices like mindfulness, ritual, dance, psychedelics and the deliberate use of trance emerged early in human evolution. These same practices are retained by many indigenous groups and have therapeutic value for them. The same is true for all of us: These ancient healing practices can take us beyond mere survival mode to a vibrant, joyful existence.

The Intuitive Therapist

If you’ve ever watched a filmed therapy session or heard Susie Orbach’s In Therapy, it might seem like there’s not much going on. The client says something and then the therapist says something. What you can’t sense, unless you’ve been there, is the deeper process going on throughout the session. As a therapist I want to be 100% present in the moment and sensitive to every nuance of our complex interaction. I also want to be aware of everything the client has ever said to me, how they might be feeling and how I’m feeling. I need to consider if, based on half a dozen theories of therapy, there’s any pattern in all that. If there is a significant pattern, I need to decide when and how to say so.

When I was training to be a therapist I despaired of ever being able to process all that and stay present with the client. I was so busy thinking about what they’d just said that I kept missing something crucial! It seemed impossibly hard. And I was right; trying to consciously think through the complexity and depth of therapy is impossible.

Most of the vast bulk of Uluru lies below ground

I’d assumed that I had to think everything through consciously, but actually about 95% of our cognitive processing happens in the other than conscious mind (Thrift, 2000). I talk about this a lot in my PhD thesis on embodied knowing, but it took me a while to appreciate how this happens in therapy. In therapy – and in everyday life – my “body senses the whole situation” (Gendlin, 1992). The wisdom of the body draws on sensory perceptions, emotions, memories, past experience and much more to decide what to do next. It’s a massive understatement to say that “your body knows much that you don’t know” (Gendlin, 1981).

Malcolm Gladwell talks about this “power of thinking without thinking” in Blink (2005). The book is full of wonderful stories about people who know intuitively what’s going on in very complex situations. There’s the art expert who can unerringly sense a fake but can’t tell you how, and a fire chief who’s gut feeling saved his entire crew from disaster. In each case the ability to correctly intuit what to do emerges from a powerful embodied knowing that’s been developed through training and experience.

In a typical therapy session I’m not constantly pondering what the client had just said: My focus is on staying present. Meanwhile my embodied mind – which has a huge range of input and a vast capacity to process that input – does the work. Drawing on this embodied wisdom is the essence of Focusing Orientated Therapy.

It’s not what you know …

… it’s the way that you know it. I sometimes have a name ‘on the tip of my tongue’. I’m sure you know that odd feeling; you both know and don’t know at the same time. We make sense of these experiences by talking about an unconscious knowing that we can’t always bring into full awareness.

But there’s a curious flip side to this: You can ‘know’ something consciously without really ‘getting it’ at a deeper level. My therapy clients will sometimes comes to a realization – an ‘Ah ha!’ moment – when they grasp something in a new way. “I knew that already, in my head, but now”, they add with a touch to the heart or stomach, “I know it here”. The difference is profound.

I first wrote about this 25 years ago in Sacred Ecology:

“Besides the cerebral knowledge we all possess, the words & ideas stored in our heads, there is a deeper knowledge held within the tissue of our bodies. It is a somatic, physical knowing which comes from direct experience. This is the knowledge of faith, of emotion, of the gut feeling”.

I later discovered that I was describing embodied knowing and went on to do a PhD on the subject (Harris, 2008).

Diagram of cognitive iceberg
Conscious knowing is just the tip of the iceberg

Embodied knowing is fundamental to my work as a therapist. In many cases a client knows exactly what’s needed, but doesn’t have conscious access to that knowledge. At other times someone will know something consciously, but lack an embodied grasp of it. The therapist is rarely – if ever – the expert. Our role is facilitating the client’s journey of growth and self discovery, which typically involves integrating their embodied knowing.

There’s another vital aspect to this which takes me back to where I started. In Sacred Ecology I wrote that we need to understand our deep relationship with the other-than-human world at the level of embodied knowing. Unless you’re avoiding the news, you’ll know, in your head at least, that there’s a climate crisis. The facts are clear and have been for years, but nothing much gets done. Action on climate change is characterized by denial and broken promises and time is running out: We may have less than 18 months to avoid catastrophic change. But unless we get that at a gut level, really feel what it means, we’ll remain in what Zion Lights calls ‘passive denial’. You may know the facts about climate crisis but, painful though it is, you have to experience the reality in your body. That wisdom of the body is like taking the red pill; there’s no going back.

When I wrote Sacred Ecology I believed that myth & ritual offered the best route to the wisdom of the body. I’ve since recognized that there are many pathways to embodied connection. These include practices that are already advocated, like mindfulness and nature connection. We need to focus in on these pathways and learn how to use them more effectively. This is embodied ecology and may be our best hope for a future.

The psychotherapy of place

How we are in the world emerges from the matrix of mindbody and place. Although it seems very obvious that where I live or grew up will influence how I feel or even who I am, that reality is largely neglected by psychotherapy. The traditional Freudian model focuses on individuals caught in Oedipal family relationships and place is all but ignored. Psychotherapy in general seems to have forgotten embodiment, although there are notable exceptions like Focusing, body therapy and some Existential approaches. But even in the more embodied psychotherapies, place is rarely discussed. The term embodiment implies place – we are all embodied somewhere – but it often seems that those working with embodiment treat place as a mere background, an adjunct to the important business of having a body.

Merleau-Ponty suggests that we have “a knowledge of place which is reducible to a sort of co-existence with that place” (2002 [1962]). It’s not that I am sitting in my room – I am in a co-existence with that space. Gendlin is even more radical: the body “is an ongoing interaction with its environment” (Gendlin, 1992). To be clear, there isn’t a typo there: Gendlin isn’t saying that the body is in an interaction, but that the body actually is that interaction.

Ecopsychology engages with the wider world, and ecotherapists might well ask about a client’s relationship to nature. But how often do therapists consider the places that we live in more generally? We typically ask about siblings, parents, intimate partners and the like, but when do we wonder about the everyday landscape of our client’s lives? “How do you feel about your home? What’s your local area like? Do you drive to work, walk or take the bus? Where did you play as a child?” If ecotherapy is about the environment rather than just the ‘natural’ world, (whatever that means), these questions are vital.

Clients sometimes talk about the fields they played in as children, how they feel when they wake up in the familiar space of home or what the corridor outside their flat means for them. I’m increasingly curious about these things, perhaps because I’m aware of the importance of this dimension of our existence. Where do we go with this? Ecopsychology has opened new pathways and my Focusing practice is sensing into this edge. There are also clues in the work of Gaston Bachelard, who proposes a new strand of psychoanalysis he calls topoanalysis. Topoanalysis “would be the systematic psychological study of the sites of our intimate lives” (Bachelard, 1969 (1958]). I haven’t had time to study Bachelard yet, but watch this space.

Forests and minds

My work as a psychotherapist sometimes leads me to imagine the mind as like a dark forest. Such metaphors have a rich history, and Inger Birkeland comments that place in general “is a concept that mediates between body and mind, nature and culture” (Birkeland, 2012).

For some indigenous peoples – and in many myths – forests are liminal places that offer the potential for change. These ancient motifs are widespread in our culture: Shakespeare’s As You Like It it came to my mind today, and serves as a rich example. In the play the Forest of Arden becomes a mysterious place away from the civilized city where dramatic transformation take place. The play is a complex exploration of contrasts and conflicts; forest/city, nature/civilization, masculinity/femininity, child/parent, love/hate. Shakespeare doesn’t provide simple resolutions of these confrontations, but leaves us to make of it what we will – as you like it, indeed.

trees_damp_21_rt_blog

The dark forest can serve as a metaphor for the inner world that the psychotherapist and client explore together. In our wandering we must accept the reality of the unknown without fearing it. There may well be something frightening in the darkness, but finding it could be transformative. We need to feel our way through the trees, not blast at the darkness with the cold analytic beam of an electric torchlight. And as joint explorers of this forest, we must stay close.

This metaphor offers some valuable insights for psychotherapy. The therapist needs to feel safe with the unknown and not try to push it away prematurely with the intellectual light of theory. Instead, the therapist stays close to the experience of their client, helping them feel their way towards change.

CBT: The ‘gold standard’ for therapy?

Cognitive behavioural therapy (CBT) is like Marmite for many therapists. Some emphasize the research results which arguably show that it’s the “gold standard of the psychotherapy field” (David, Cristea and Hofmann, 2018). Others, like Richard House, see it as a “therapeutic technology” backed by a research regime that misses vital aspects of therapeutic practice; “subtlety, intuition, discernment and ‘the tacit’ in human relational experience” (2010).

Given that my original therapeutic training was with two of the most vehement critics of CBT – Richard House and Del Loewenthal – it seemed odd to some colleagues that I completed a Professional Certificate in CBT. One jokingly suggested that I’d “gone to the Dark side”!

At first CBT didn’t sit well with my existing approach, which is very much grounded in those qualities Richard extolled; subtlety, intuition and tacit embodied knowing. But I sensed that there was something of value here, notably because I’d unwittingly used CBT techniques to tackle my own anxiety in the past. Several years ago I started getting anxious about whether I’d locked the front door. I’d be about to cycle off to work when the thought would come: ‘Did I lock the door properly?’ My rational mind knew very well that I had: I’d  been successfully locking my front door every day for years! But the doubt nagged at me. The first couple of times I went back to check and it was, of course, fine. But I knew this wasn’t right because I was pandering to my irrational concerns. So I stopped checking. Sometimes it was quite hard. That voice in my head said: ‘It’ll only take a second to check, and then you won’t have to worry any more.’ I countered that with reason: ‘There’s no need to check. I already know it’s fine’. That’s a classic CBT approach and it worked very well: The worry went away instead of growing into full blown OCD!

But CBT doesn’t work for everyone. I’ve had several clients tell me that they tried CBT and it just didn’t work for them. Typically their CBT was provided on the NHS and the therapist didn’t know any other way of working. Why bother to learn anything else when CBT is the “gold standard”? This is part of the reason why CBT has such a bad name amongst some therapists: CBT is presented as the solution in a ‘one size fits all’ approach.

There’s some evidence that CBT is becoming less effective. A paper from 2015 looked at 70 CBT trials and found that the impact of the treatment for depression was falling (Johnsen and Friborg). The authors suggest several possible reasons for this decline, with the most likely being a reduction in therapist competence. What made CBT so attractive to the NHS was that it can be done by the book. In theory anyone who knows how to follow a step-by-step guide and can demonstrate the exercises to a client can be CBT therapist. But we know from extensive research that technique contributes no more than about 20% to the outcome of therapy. Those vital elements that Richard House highlighted above – subtlety, intuition, discernment and tacit knowing – are much more important.

I’m pleased I persevered with CBT. My trainer – a therapist with many years of experience – emphasized that CBT works best when it’s used creatively by an empathic, open minded therapist. It also opens the door to further training with the ‘third wave’ of CBT that integrates it with mindfulness.

CBT isn’t just one more technique in my ‘tool box’: It’s more like another pattern to weave into the rich tapestry of my therapeutic practice. As Richard House points out, the key to good therapy is how it’s practised, not which techniques are used (ibid.). To put it more crudely, it’s not what you do, it’s the way that you do it!

The Embodied Pathways of Connection in Therapy

My previous post introduced the EPOC, embodied practices that can reveal our radical interconnectedness. I initially came across the EPOC during my PhD research into spiritual eco-activism: The EPOC both inspired and supported the campaigners I worked with (Harris, 2008). Years later I noticed something curious; the EPOC I’d identified amongst road protesters seemed to underpin much of psychotherapy!

That may initially sound implausible, but the deeper I’ve looked into this apparent link, the more sense it makes. My research with activists identified seven EPOC; nature connection, meditation, Focusing, ritual, dance, trance and psychedelics. These seven all map to psychotherapeutic practices:

  • nature connection is the foundation of ecotherapy;
  • mindfulness meditation is at the heart of third wave CBT;
  • Focusing is a therapeutic practice;
  • psychedelic psychotherapy may be the next big mental health breakthrough;
  • dance therapy has been around since the mid-60s’;
  • ritual is widespread in psychotherapy, while
  • trance is an altered state of consciousness which is common in psychotherapy.

This is a big subject, but there’s two points I can make about how the EPOC function in psychotherapy. First, the EPOC facilitate access to embodied knowing and that process is fundamental to how psychotherapy heals. Second, they can dramatically widen our perspective: If you’re focusing too much on your own mental processes, mental distress is often the result.

John Kabat-Zinn launched the therapeutic mindfulness revolution that’s transformed the lives of millions. He believes that connection is fundamental: “the quality of the connections within us and between us and with the wider world determines our capacity for self-regulation and healing” (Kabat-Zinn, 2013).

Many Focusing Oriented Therapists speak of that connection too: “Focusing allows our consciousness to settle into that area in ourselves where there is physical in-binding with the rest of the cosmos” (Campbell and McMahon, 1997).

Research into how psychedelic psychotherapy works has come to the same conclusion: “a sense of connectedness is key” (Carhart-Harris, et al, 2017). The theme of connection also runs through dance therapy: Connecting the mind and body, the conscious with the unconscious, the self with the other (Halprin, 2002).

This leaves ritual and trance, which are both complex and multifaceted. I’d argue that ritual is fundamental to many psychotherapeutic approaches and my experience of psychoanalysis felt deeply ritualistic. But for the moment, I’ll be more specific and reference Family Constellation Therapy (FCT) which explicitly draws on African healing ritual. FCT is based on the notion of the ‘knowing field’ a web that “propagates information and affect through the family and ancestral network” (Adams, 2014). That sounds strange to Western ears, but accords very well with Eugene Gendlin’s claim that “Your physically felt body is in fact part of a gigantic system of here and other places, now and other times, you and other people. In fact, the whole universe” (1981).

Trance is much more common than many of us suppose: When you’re watching a film or reading a novel, you’re most likely in trance. Hypnotherapy is of course the most obvious use of trance in psychotherapy but it’s arguably more fundamental. Furthermore, nature connection, meditation, Focusing and psychedelics can all induce an altered state of consciousness which we might call trance. On that basis, trance can certainly facilitate a sense of deep connection. There’s also a powerful association between psychotherapy and shamanism which gives trance a central role (Thalhamer, 2015). Boundaries get very blurred at this point because Shamanism is intimately engaged with nature connection and can include aspects of meditation, Focusing, dance, ritual and psychedelics.

We’re now close to the place to which these embodied pathways of connection all lead. For Glen Mazis this place is about ‘earthbodying’; Philip Shepherd names it “radical wholeness” (2017); David Abram might speak of participatory perception (2010), while Susan Greenwood writes of “a heightened awareness of an expanded connected wholeness” (Greenwood, 2005). For me this place is characterized by a particular kind of embodied knowing, the “wisdom of the body; that all things are ultimately one” (Harris, 1996).

Psychedelic psychotherapy: The next big thing in psychiatry?

The UK Home Secretary has announced a review of cannabis for medicinal use. Does that bring psychedelic psychotherapy a step closer? When LSD was synthesized back in the 1950s psychiatrists were quick to see its potential. Research proliferated over the following decade, producing over 1,000 peer-reviewed clinical papers. The results were overwhelmingly positive and “psychedelic therapy was truly considered the next big thing in psychiatry” (Sessa, 2017).

So what went wrong? Several factors came together to stop what could have been a revolution in psychotherapy. Millions of people were taking LSD recreationally, and perhaps inevitably there were casualties. Psychedelics open us to experiences that the more reactionary elements of society find weird at best and even threatening, so it’s no wonder that the press leapt on any negative news. Psychedelics like LSD are the most powerful mind changing substances that exist and deserve to be treated with respect. There are a few basic principles to using psychedelics: Are you in the right mental state to take them? Is this the best place and time for the trip? Carefully considering these essentials – commonly known as set (mindset) and setting – will very much reduce the risk of a ‘bad trip’. In a psychotherapeutic context set and setting are carefully controlled and the whole process is facilitated by a trained professional.

A second factor was the rise of antipsychotic drugs which led to less emphasis on outpatient psychotherapy sessions. Someone with a more conspiratorial turn of mind might also point out that psychedelic psychotherapy promised a permanent cure for many mental health disorders. People who are cured don’t need a daily dose of expensive drugs to keep them feeling (kind of) OK.

The psilocybin molecule

The good news is that research into psychedelic psychotherapy is undergoing something of a renaissance. Clinical research using psilocybin (the active ingredient of ‘magic mushrooms’), MDMA (ecstasy), ketamine, ayahuasca and LSD is ongoing. Psilocybin looks especially promising. A recent review of seven clinical trials found “large effect sizes related to improved depression and anxiety symptoms” (Thomas et al.) The results overall are encouraging: Psychiatrist Dr. Ben Sessa concludes that psychedelic psychotherapy “is a cost effective way of treating otherwise unremitting mental illness” (Sessa, 2017).

Why is psychedelic psychotherapy so effective? According to one influential paper, one of the key processes is a shift from “disconnection (from self, others, and world) to connection” (Watts et al., 2017). I’m hugely excited by all this, not least because there are some parallels with my PhD research. My research suggests that what inspires and supports many environmental activists is a profound sense of connection. The experience of living close to nature and practices like mindfulness help facilitate this, as does the use of psychedelics like psilocybin. Could it be that a sense of connection – or reconnection – is the underlying mechanism behind our sense of wellbeing?

The Neuroscience of Walk and Talk Therapy

Susan Greenfield is a leading thinker on the neuroscience of consciousness, so I was curious to learn that she believes walking can help us think. Do her ideas help illuminate how ‘walk and talk’ ecotherapy works? Walk and talk therapy is much like conventional counselling but takes place outdoors. Therapist and client walk side by side exploring issues just as they would in the consulting room. Walking and talking in the park feels familiar to most people and being alongside the therapist avoids the potentially uncomfortable feeling of sitting opposite them.

Walk and talk therapy is increasingly popular and Susan Greenfield’s work suggests that it might also be very effective. Walking in natural environments has been shown to boost cognitive capacity, improve working memory and enhance recall. Susan describes other benefits:

“It is you who decides to examine a plant more closely or to focus on the far-flung horizon one moment, then perhaps to lean up against the tree the next: this internally driven sequence of events will then have the additional benefit of restoring a sense of control, of giving you a longer time frame in which to develop and deepen your thoughts”

(Greenfield, 2016)

Although Susan is writing about walking in nature, she has perfectly described a typical ecotherapy session.

Follow the path …

Susan suggests that as thinking is basically a series of steps, it can be seen as “a kind of movement: the longer the journey, the ‘deeper’ the thought”. She adds:

“the actual physical act of walking could amplify and thereby perhaps enhance this inner process: by reflecting in external movement what is happening in the brain, by having a clear causal link between one step and the next, with the mental being enforced by the physical, the repetitive contraction of muscles could help insure against the mind ‘wandering’, going, literally, off-track”

(Greenfield, 2016)

Everything that Susan Greenfield says about walking in nature suggests that walk and talk ecotherapy will enable clients to think more deeply and powerfully. Furthermore, the therapist will benefit in the same way, so we can do our job better. Susan Greenfield may have never heard of walk and talk outdoor therapy, but the fact that her neuroscience research unintentionally supports what we’re doing is exciting news.