Walk and Talk Therapy

Nov 1 / Juniper Owens
As many mental health professionals can attest to, sitting in an office all day can be mentally and physically draining. Telehealth adds to the toll, as you are attentively staring at a screen for hours on end. Many years ago in my clinical social work career I started wondering about the impact of sitting and being indoors for long periods of time, especially when providing and receiving services.

I have many theories of why I was feeling so drained and uncomfortable after being in the office for long periods and why walk and talk therapy seemed to improve my mood, ability to hold space for my clients and remain mindfully
attuned, focused, and regulated. The same theories might apply to my clients who decided to try walk and talk therapy. They seemed to have improved mood that was sustained long after the session. They reported feeling more comfortable, more "themselves". I noticed many more breakthroughs and powerful releases.

When I first started looking into the potential benefits of walk and talk therapy, I started with the research. How much time are people sitting and spending time indoors and what are the implications? It might not come as a surprise that most modern humans, living in urban areas, spend the majority of their time indoors.

Americans sit almost 10 hours a day on average and research has been looking at the consequences of that. In one 2018 study, from the Annals of Internal Medicine, 8,000 adults showed an association between prolonged sitting and a risk of early death from any cause. (People who sat for no more than 30 minutes at a time had the lowest risk in that study.) Other research has linked prolonged sitting or other sedentary behavior to diabetes, poor heart health, weight gain, depression, dementia, and multiple cancers. I personally have noticed issues with weight gain, lethargy, fatigue, increasingly sore hips and abdominal muscles, and generally being less embodied in session.

Dr. Levine, researcher and physician with the Mayo Clinic, states that there are more than physical health implications with prolonged sitting. There are negative correlations with sedentary behavior and increased anxiety, depression and general malaise. Dr. Levine believes that because the human brain evolved to "control" a moving body, not a stationary one, some areas of the brain can become stagnant and there can be a misfiring of neurotransmitters (such as dopamine for example). He goes on to discuss the evolutionary process of how humans have been in what he calls "the chair sentence", starting during the industrial revolution. He describes this process as very slow and overtime has become the norm for many humans.

Being sedentary isn't necessarily due to individual character or lack of will, but instead a product of environmental factors that support and even force sitting for long periods of time like in schools, offices and transportation. And it's not just the sitting that is potentially causing harm to health and wellbeing, but also the length of time we spend inside buildings and vehicles.

Americans spend approximately 90% of their time indoors on average. Researchers have pointed to decreased immune functioning due to lack of vitamin D. The correlation between excessive time indoors and depression/anxiety has also been researched a great deal. Lack of sunlight can affect circadian rhythms, which can disturb sleep patterns. This is a key point to note since we know that sleep can contribute to all mental health issues, especially depression and anxiety.
A growing body of research indicates that simply being in the presence of nature has positive effects on our physical and mental well-being. Some clients might prefer the outdoors. Some clients may also be more comfortable saying what is on their minds when walking side-by-side rather than sitting face-to-face in an office. I have noticed that both myself and my clients tend to be more open and talk more freely when we are walking.

This is also an opportunity to see the client in a different setting. If I am working with a client who has goals related to social anxiety or social skills, for example, we might
go to a coffee shop and order a drink. I have noticed that triggers often do not appear in an office session, as it is usually a safe controlled environment, so it can be difficult to actually experience the uncomfortable sensations or to practice coping skills there. Sometimes I will suggest out of office sessions when a client is feeling well resourced and is ready to experience an edge of their window of tolerance.

Benefits of Walk and Talk Therapy

  • Relieve muscle tension
  • Increase focus
  • Decrease anxiety
  • Promote restful sleep
  • Increase embodiment and somatic awareness
  • Increase vitamin D levels
  • Improve brain functioning
  • Boost serotonin
  • Calm the nervous system
  • Improve circulation
  • Shift the power dynamic or positionality of traditional talk therapy sessions
"Walking is the quickest anti-depressant
on the market today."
-John Arden, PhD


In the video to the left, "Walk and Talk Therapy" founder, Clay Cockrell, discusses how he started using New York's Central Park as his office all year round.
I first started doing "walk and talk" therapy when I worked in the school system as a clinical social worker. I found that when kids got outside, they instantly relaxed and were able to share and process more. I think being outside of their school or home where they have less control and privacy really made a difference. I noticed their energy levels increased and teachers reported less behavioral issues and increased focus.

When I was working mostly with adults in a private practice setting around 2015, I started offering walk and talk sessions near my office. Most clients reported feeling more comfortable with me and an improved therapeutic relationship, since I was walking with them side by side, rather than staring at them in a therapy office. I had a few clients discuss the inherent power dynamics of therapist and client and that they feel less pronounced when outside of the office. Other clients reported feeling better having some movement in their day, which improves self-confidence, like they checked something off their to do list.

Alternatively, I have had some clients that prefer to be in office for many reasons. One mentioned they had trouble focusing due to the army of city sites and sounds and that they preferred to take notes, which is difficult while walking. Walk and talk is not beneficial for every client and that is why it is important to have consent and shared goals.

Clinical Considerations

  • Possibility of seeing someone you or your client knows
  • Possibility of you or your client being injured
  • Less control over the privacy of your session
  • Your own feelings on conducting a session while outside of your office
It is important to use your clinical skills and wisdom to evaluate if a client is a good candidate for walk and talk therapy. There are many considerations, but we will only get into a few of them today. I typically will not recommend walk and talk therapy for those whose safety could be threatened if they are seen outside of the office, like one who is in an abusive relationship. I also usually don't do walk and talk sessions with newer clients who I don't know much about or with those who have significant difficulty with emotional regulation until the client has more resources. Crisis sessions are typically not done outdoors either. Lastly: use your judgement.
You have the skills and knowledge to get a sense about what is right for you and your clients.
It is always important that it is the client's choice, therefore having consent would be the most important clinical consideration. You can use a signed release of liability form to further protect you and emphasize client consent. We have a handout that can be used in session to explore the above considerations as well as a customizable consent form that you can use in your practice, see our Walk and Talk Starter Pack in our course library.

One of the most common concerns I hear from other mental health providers is the privacy and confidentiality issue. When you leave the relative safety of the closed office door the chances of seeing someone you or your client knows increases. You have less control over the privacy of your session. Before you take a client outside of the office, it is important to discuss with them (or, when working with kiddos, their guardians if appropriate) these possible scenarios. I usually say something like, 'there is a possibility we might see someone we know, and it is up to you and your comfort level of how it is handled.' Sometimes we might role play a scenario if a client feels anxious about it, but usually they don't have any concerns. I have occasionally run into someone I know while walking with a client and, while it is not in my nature to be short with people, I typically just say hi and keep walking. If they try to continue the conversation I just say I am busy and can't talk. It's really that simple.

The last thing I have heard from the new therapists I supervise, or those I train in integrative mental health practices, is how being outdoors affects your mind and body, including regulation, focus and professionalism.
For example, I notice that I tend to stay more focused and intentional when I am working with clients outside of the office. I also notice that I am more casual outdoors. I mostly notice it with the way I talk and how I behave, so I have spent time consulting with peers on how to address any potential issues that I personally bring to outdoor sessions.

Sometimes, when walk and talk therapy isn't clinically appropriate or of interest to a client OR when the weather doesn't allow, I often recommend what I call intentional or therapeutic walking. Essentially, it is similar to walk and talk, which is thinking or processing an issue or topic while walking.
I got the idea after I was first trained in EMDR. I learned about how the founder of the modality, Francine Shapiro, discovered it while walking in Central Park. She was experiencing emotional distress, thinking about a memory and while walking and looking back and forth (left to right) and noticed a decrease in the emotional intensity. While the research in EMDR focuses on the eye movements (which is a whole other conversation), many current-day practitioners of EMDR focus on bilateral stimulation. This lead me to wonder, if simply walking while thinking about specific memories, issues or thoughts could have a similar effect. While I haven't been able to drudge up much research on it, I tested it out personally and many of
my clients have tried the same approach with very interesting results.

I do some of my best thinking while I am walking or running. I can access more creativity and new solutions present themselves, like if I am thinking about a tough conversation I have coming up. I think of things that I hadn't previously considered. I can also think about distressing events with more ease. I can also cry easier, which can be therapeutic for me.

The practice I recommend is to intentionally think about a topic, often that we are addressing in therapy, and start with that in mind. Or if we are working on distress tolerance, for example, bring a distressing feeling or thought to mind. Then you just let it go. Start walking and allow the mind and body to just wander. Don't try to control it. Just allow whatever happens to happen. Using the bilateral stimulation of walking and accessing the brain changes that occur while being in nature, shifts in perspective and new ways of feeling and thinking can be experienced.

As an example, if you are working on identifying negative thought patterns, you start with a phrase you have identified, like "I am so stupid and worthless, I will never find love". Start your walk by repeating the phrase either silently or out loud and then walk for 5-10 minutes paying attention to what you are noticing. What thoughts are drifting in your mind? How does your body feel? After the walk jot down some of your observations.

Another walking practice I recommend outside of session is a walking sensory experience. The invitation is to choose a sense to focus on, hearing or touch, and spend a 5-10 minute (or more) walk focusing mostly on this sense. To help stay focused, I often recommend for clients to bring tools with them to help record what they are noticing. If you are focusing on your sense of sight, you can bring a camera to snap photos of what you see. You can also create a sensory scavenger hunt and write down a list of four textures to find and describe what you notice when you feel them.

If walking is difficult or impossible for a client, due to chronic pain, injury or different ability, then a similar practice can be to place yourself outside or in front of a window while starting with the topic or issue. Sometimes I might recommend any movement that is tolerable, such as swaying back and forth, tapping arms or legs or even just following movement outdoors, like watching plants move in the wind or a squirrel running past.

These are just a few examples of walking practices you can recommend. During a walk and talk therapy session, you can utilize the modalities you prefer best. In walk and talk therapy, the way you typically conduct a session is the same- you are just walking instead of sitting in an office.
References
Environmental Protection Agency. What are the trends in indoor air quality and their effects on human health? EPA.

Katella, K. (2019, August 28). Why is sitting so bad for us? Yale Medicine.

Levine, J.A. (2015). Sick of sitting. Diabetologia, 58(8).
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