What Is Outdoor Therapy? A New Name for an Old Therapeutic Practice

Nevin J. Harper ^1,* , Will W. Dobud ² 

1. School of Exercise Science, Physical & Health Education, University of Victoria, Canada

2. School of Social Work and Arts, Charles Sturt University, Australia

* Correspondence: Nevin J. Harper 

Academic Editor: Marianna Mazza

Received: June 21, 2024 | Accepted: October 27, 2024 | Published: November 07, 2024

OBM Integrative and Complementary Medicine 2024, Volume 9, Issue 4, doi:10.21926/obm.icm.2404065

Recommended citation: Harper NJ, Dobud WW. What Is Outdoor Therapy? A New Name for an Old Therapeutic Practice. OBM Integrative and Complementary Medicine 2024; 9(4): 065; doi:10.21926/obm.icm.2404065.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

The forest was a tangled bank tumbling down to the grassland’s border. Inside it was a living sea through which I moved like a diver groping across a littered floor. But I knew that all around me bits and pieces, the individual organisms, and their populations, were working with extreme precision. A few of the species were locked together in forms of symbiosis so intricate that to pull one would bring others spiralling to extinction. Such is the consequence of adaptation by coevolution, the reciprocal genetic change of species that interact with each other through many life cycles. … It is enough to work on the assumption that all of the details matter in the end, in some unknown but vital way. ~Edward O. Wilson [1].

1. Introduction

Eminent American sociobiologist and Pulitzer Prize-winning author, Dr. E. O. Wilson pioneered scientific inquiry into narrow topics, such as his entomology research with ants, but also with breadth, recognizing coherence of interspecies dependence. His theoretical work on the biophilia hypothesis, or the love of life (or all living things), is commonly cited in outdoor therapy literature [2] as it explores the evolutionary and psychological relationships of humans and the natural world.

Wilson, while celebrated for his prolific dedication to conservation, was not met without criticism from some of his colleagues for positioning humans as just another species living on the earth, suggesting human traits are evolutionary and genetic, and denying a human-nature dichotomy [3]. Wilson’s point, humans are nature. There exists a pervasive false dichotomy used in the English language, perpetuated, even in our modern dictionaries, that nature is the collective physical world, humans being other than nature [4]. Outdoor therapy providers recognize this contradiction as a key aspect of addressing human suffering from psychological distress and the associated range of mental health, behavioral, and addiction struggles [5].

Human health is influenced by the quality of the environment in which one lives or is exposed to. Here, there is no debate. Nineteenth century progress in sanitation, clean water systems, minimizing toxins like lead in paint and gasoline, and addressing air quality improved the health of populations globally, although significant effort remains warranted [6]. Our modern, hurried, and contaminated world, where many of us spend our days, slowly reduces the potential for optimal health [7]. A commonly cited 2014 study, for example, showed Canadians spent about 21 hours each day indoors, an additional hour in their vehicles, and nearly 90 minutes outdoors, which mostly included movement between indoor environments [8]. Reality is, many humans are spending more of their lives in built versus natural environments.

Additionally, global statistics related to screentime and the negative effects of social media and digital interference [9] suggest the internet increased our disconnect from nature despite smart phones, high-speed internet, and affordable technology; all of which promised to connect citizens of the world [10]. In this paper, we examine the commonalities and distinctions among outdoor therapies and propose an evidence-informed contextual model illustrating the pathways of change related to outdoor therapies.

1.1 Expanding Therapeutic Space

Coupled with conventional approaches to psychotherapy and therapeutic care, it is in direct contact with natural environments and engaging clients with experiential activities that the outdoor therapist practices [11]. We, along with other outdoor therapists, call modern psychotherapy conventional instead of traditional, to recognize ancestral and evolutionary ways of being, such as living in closer contact with nature, which seems almost forgotten in the helping professions, although interest appears to be growing.

Outdoor therapies are not innovative, new, or cutting edge; what is old is simply new again. As William James [12] said when referring to pragmatism, the philosophy grounding much of the origin of American psychology, outdoor and experiential instruction, and outdoor therapies subsequently, this is a new name for an old practice.

Increased time in healthy natural environments has been shown to improve mood, reduce stress, and improve affect [13]. Cross-sectorial research agendas and resultant community action reflects a growing interest in the ways in which contact with nature can restore health benefits lost through disconnected and contaminated spaces we spend much of our lives [14,15,16]. Maybe most obvious, but now well evidenced, actively engaging in greenspaces (i.e., forests, gardens) and bluespaces (i.e., beaches, rivers) produces healthier outcomes than the same levels of activity indoors [17,18].

Numerous positive associations between nature-based recreation and mental wellbeing have been demonstrated [19] and include the adoption of the medical model language of dose [20,21]. Mental health interventions and population health promotion strategies now commonly utilize contact with nature and outdoor physical activity [22,23]. ‘Nature-based’ solutions is a term quickly gaining prominence across fields of inquiry as a response to social, environmental, and psychological problems [24,25].

Building on the history and relevant evidence, we present the commonalities of outdoor therapies, and examine their use based on current trends in psychotherapy. We argue that while outdoor therapy approaches, while not new to the helping professions, may improve access and engagement for a range of clinical populations. We illustrate in the following section that the experiential understanding of the therapeutic value of time outdoors was not adjunct to social work, psychology, philosophy, or sociology at the founding of these concepts and professions, it was central.

2. Nature and Therapy

Edward Wilson’s quote above tells of the relationships all species require for balance, for optimal health. Prominent voices in therapeutic care knew this more than a century ago. Considered the mother of American social work, Jane Addams, who established the Bowen Country Club through the Hull House social settlement home. From 1912 to 1963, nearly 40,000 people engaged in outdoor activities, art lessons, and camping. The camp was designed to create a place where “children from many national, racial, and religious backgrounds learned to respect each other and the environment” [26]. Co-founder of the American Psychological Association (APA), director of the first lab of psychology, and overseer of the first PhD of psychology in America, William James, was active in the outdoors, often hiking the Adirondack Mountains of New England. James’ rejection of the divisive duality of humans and nature meant only pure experience in the outdoors could lead to an empathetic kinship and meaning between humans and the ecosystem [27]. Swiss psychiatrist Carl Jung’s writings showed “how healing our own living connection with Nature contributes to the whole” [28]. Important founding voices of the therapeutic professions acknowledged the critical importance of outdoor environments for therapy, though this appears eclipsed in modern, conventional psychotherapies. The medical model of psychotherapy appears to view healing contained within the person, overlooking the human-nature kinship. Yet, there exists an explosion of interest and service offered in natural healing in the health and wellness space (e.g., cold plunges, nature connection walks, rural or wilderness retreats etc.).

Modern Western society has experienced increased disconnect from nature, be it direct contact with natural environments, or the distancing of one’s sense of their place in the world, their sense of being one small part of something greater, what leading environmental thinker Thomas Berry [29] referred to as the sacred community of Earth. In this disconnection, we find dis-ease and dis-order. When well-integrated, we find restoration, rejuvenation, and re-creation [30]. Along with colleague and Danish physician C. G. Lange, William James developed a theory of emotion in the late 1880s which described human emotions as being generated by physiological responses to events in our lives [31]. To us, this sounds parallel to many outdoor therapists who center active bodily engagement and experiential reflection in their clinical work [32] and we find empirical support for these practices across health and psychotherapy literature [33,34].

The APA [35], across their 54 divisions, list hundreds of therapeutic approaches. Meichenbaum and Lilienfeld [36] argued the number of psychotherapy models are now more than 1,000. When we consider health promotion practices and wellness approaches, such as those including exercise, diet, and sleep patterns, those numbers likely double, or triple. While contact with nature for health and wellbeing promotion is well-evidenced [37], and known for centuries, the mechanisms and theories of change are less than well understood, though researchers and theorists have tried to articulate possible pathways to health outcomes stemming from nature contact [15,38].

Kuo [39] put forward what she called “plausible pathways” (hypotheses of mechanisms of change) following an extensive review of the literature; including environmental factors, physiological and psychological states, and behaviors and conditions which each have ties linked to health outcomes. Environmental factors include chemical and biological compounds which affect human health. Examples include volatile organic compounds, such as phytoncides from trees (i.e., essential oils, pollens, etc., negative ions, mycobacterium, and natural sights and sounds). Markevych et al. [40] extended the pathways approach citing three ways greenspaces contribute to health improvements: reducing harm (e.g., quiet spaces, pollution control), restoring capacity (e.g., improved focus, reduced stress), and building capacity (e.g., physical and social engagement). Complex relationships between humans and environmental factors limit our understanding of what contributes to therapeutic outcomes in outdoor therapies and this is reflected in a lack of theoretical development [41,42]. Cooley et al. [43] assessed practitioner views on therapy in natural spaces and identified a range of benefits which they describe as enriching the therapeutic process, such as strengthening relationships between client and therapist, and the promotion of health and wellbeing for practitioners.

We do know that physiological and psychological states which promote health outcomes may include restored attention, balanced blood-sugar levels, increased vitality, reduced stress. Combined with activity in nature, further benefits include improved sleep, weight reduction, and increased social ties through group activity in nature. Outdoor therapy researchers [44] simplified the pathways description specific to outdoor therapies by depicting the following relationships: physical interventions in nature lead to biological and physiological outcomes; therapeutic engagement and support leads to mental health outcomes; social engagement in group activity leads to peer and family cohesion and adaptability. While commonsensical in description, very few of these claims have been met with empirical testing in psychotherapy, though numerous benefits are known beyond the helping professions, such as the benefits of time spent in green and blue spaces.

3. Green Prescriptions and Bluespaces

Greenspaces, and more recently bluespaces, have been used as descriptors of interventions utilizing activity in natural environments for health promotion, disease prevention, and treatments [45,46]. Stanhope and Weinstein [47] conducted a scoping review of how the term green prescriptions has been used in the health and medical science literature. They stated that the phrase “has been used since 1997 to mean a written prescription for a lifestyle change, most commonly physical activity [and/or diet], provided by a health practitioner” (p. 155), yet since 2014, the phrase has also meant exposure to nature, yet consistently infers a prescription for physical activity. Stanhope and Weinstein criticized the now inconsistent use of the term in research evidence and suggested nature prescriptions to better describe the latter 2014 addition of exposure to nature in the research literature.

In another recent systematic review of green prescriptions [48], we found nature-based therapy, nature-based solutions, forest therapy, and bluespaces included. This contrasts with Stanhope and Weinstein’s suggestion to protect the green prescriptions term for physical activity and diet protocols. Regardless of the inclusion/exclusion of certain forms of green or nature prescriptions for physical and mental health benefits, the evidence-base is rapidly growing [49,50]. North Americans have been more recently introduced to parks prescription (e.g., PaRx, www.parkprescriptions.ca) in which a variety of healthcare providers are ‘prescribing’ time in nature.

Bluespaces have received more attention in recent years and follows naturally greenspace research demonstrating health and wellbeing outcomes [51,52]. A 2010 review paper from UK researchers Barton and Pretty [53] garnered significant attention as they analyzed 10 separate studies with a combined 1252 participants in green exercise interventions. They found a dose of 120 minutes of activity in nature ideal to produce positive outcomes, such as improved self-esteem and mood. The researchers also found the greatest effect for those who needed it the most (i.e., mental health diagnoses), and that the presence of water boosted the outcomes during green exercise interventions. Being near water, especially moving water, appeared to produce higher levels of negative ions in the air which has beneficial effects on brain function, increases sense of wellbeing, improves cognitive performance, and could be related to improvements in depressive symptoms [54]. Further research is needed to confirm the range of health effects of being in or near water, but indications are present in the literature [55] and common sense suggests the healthful and restorative effects of sitting by a babbling stream, watching waves crashing on a beach, or swimming in a lake. While the health benefits appear robust, the role of the therapists, or facilitator, remains unclear as to how to maximize these effects during therapeutic service delivery. Here, we explore how these environments and experiences have been integrated into therapeutic practices.

4. Outdoor Therapies

Outdoor therapies is an inclusive categorization of approaches sharing enough common characteristics, allowing for ongoing research to advance clinical utilization, build a community of practice, and most critically, to improve service to clients [10,56]. Previous terms used to classify these approaches includes adventure therapy and ecotherapy [2,57]. These are but two examples of categorization but have not been taken up broadly as both terms can be understood as somewhat specialized. Some therapists do not relate to adventure, some do not relate to working with human-environmental relationships and ecological philosophies. Outdoor therapies have been defined as therapeutic approaches comprised of three central elements: they are (1) place-based, primarily outdoors; (2) feature active bodily engagement, and (3) recognize the nature-human kinship [56].

A recent survey of outdoor therapies was presented in an edited text from practicing clinician researchers Harper and Dobud [10], including foundations for practice, a collection of more distinct therapies, as seen in Table 1, related theories, and case studies to depict their commonalities and uniqueness. Foundational practices include: the facilitation of experiential activities and experiences, and recognition of ancestral and Indigenous ways of being in the world (i.e., human-nature interconnectedness) that reflect an eco-psychology, activities that engage the client in body, mind, and spirit, nature connection and relationship building, including the reciprocal human relationship with the natural world. Specific forms of outdoor therapies manifest as specialized approaches. Examples are shared in Table 1.

Table 1 Outdoor Therapies with Practice Descriptions and Examples.

While an evidence-base grows in outdoor therapies, each distinct approach shown in Table 1 and more (e.g., surf therapy, green and blue social/health prescriptions, outdoor therapeutic recreation, etc.) continue to refine practices to better understand mechanisms of change and understand possible causal relationships [37]. It is known that outdoor therapies are guided by experiential activities in nature, and that underlying practitioner beliefs represent the philosophies of ecopsychology, that human-nature relationships are reciprocal, and that the health of the human is related to the health of the environment [65]. We know this to be true from a century of population health research showing, for example, clean drinking water and effective sanitation and hygiene prevents illness [5]. By extension, we know a meaningful relationship and connection with nature is a requisite element for optimizing human health.

5. Common Factors in Outdoor Therapies

In conventional talking psychotherapies, common factors include those related to each individual client (i.e., motivation, extratherapeutic factors), the therapeutic relationship (i.e., relational bond between client and therapist), hope and expectancy (i.e., placebo), and the presence of a therapeutic model with a rationale and specific interventions (i.e., cognitive-behavioral or psychodynamic therapy) [66,67]. While tempting to describe models of therapy based on what differentiates them on the surface, these common factors make up the majority of variance in psychotherapy outcomes.

Despite attempts to carve out a niche for outdoor therapies as an alternative approach to psychotherapy, we cannot define or describe outdoor therapies without acknowledging these common factors are inherent to all psychotherapeutic approaches. To differentiate, we briefly explore the specificities of outdoor therapy practice which may be unique from conventional practice. Figure 1 provides a visual representation of a theoretical framework [56] for outdoor therapies which brings attention to the three common factors that differentiate it. First is the presence of a practitioner who may be a clinically trained therapist or a worker tasked with facilitating a therapeutic experience outdoors. The practitioner is in a responsive and collaborative relationship with the participant, who some may refer to as service users, consumers, clients, or patients.

Figure 1 Proposed theoretical framework and the three common factors of outdoor therapies.

Influencing the interaction between the practitioner and participant is the purpose or meaning behind their relationship. The participant is engaging in the outdoor therapy service for a specific purpose or complaint, whether designed for symptom reduction, behavioral health issues, or to improve wellbeing. The practitioner is also informed with a rationale and theoretical orientation for tailoring the service to the participant’s purpose for engaging. This rationale informs the practitioner’s decision making throughout the outdoor therapy process and pragmatically, this will evolve throughout the responsive relationship between the participant and practitioner. We here recognize that some practitioners will engage outdoor therapy instrumentally (i.e., outdoors for therapy) while some practitioners aim for integration (i.e., outdoor therapy as a vehicle for increased human-nature connection).

This theoretical framework for outdoor therapies is contained within an evolving therapeutic and helping relationship, a part of which is the therapeutic alliance. Bordin [68] defined the therapeutic alliance as containing (1) a relational connection between the practitioner and participant (i.e., bond), (2) agreement on the purpose of their work together (i.e., goals), and (3) agreement about how they will work together (i.e., tasks). It is in this therapeutic and helping relationship the practitioner and participant can engage in the three common factors of outdoor therapies described above: (1) place-based; (2) active bodily engagement, and (3) the nature-human kinship [56].

This representation for outdoor therapies provides direction for progressing focused research which has been called for [38,43] to examine the diverse range of outdoor therapeutic modalities. This inclusive and welcoming model invites a range of practices beyond those tabled above. Walk and talk therapy, therapeutic recreation, therapeutic climbing, nature-based art therapy, and others have been described in the literature and fit theoretically under the umbrella of outdoor therapies. Further, cultural and spiritual traditions globally have elements of nature connection and ancestral ways of knowing and being that have been integrated in outdoor therapies when and where appropriate within the practitioner’s scope of practice and competence.

6. Pursuing a Nascent, Progressive, and Diverse Research Agenda

Thinking about therapy and the outdoors was once a norm, yet recently we have seen it proposed as a “new and innovative strategy” [69]. It is not. Maybe as we continue to research and understand mechanisms of change, and how different environmental features may influence different people, we may be able to lay some claim to nascent knowledge contributing to emerging, hopeful, and ultimately promising new ideas and conceptualizations surrounding outdoor therapeutic work.

Most common to outdoor therapy research are program evaluations, or the administration of pre-and post-outcome measures to determine if wellbeing was improved or symptoms reduced during a specific outdoor therapy intervention [70]. Wampold and Imel [67] used the work of Hungarian philosopher Imre Lakatos to describe how the field of psychotherapy can adopt a progressive research program. The medical model of therapy continues to influence the dominant research agenda, using clinical trials to locate which approach to therapy is more effective than the next, while seemingly ignoring the common factors likely influencing treatment outcomes. This limited approach provides macro-level knowledge to base system-wide decisions on (e.g., repeated outcomes studies may leverage access to third-party insurance providers when enough “evidence” is provided). To advance outdoor therapy research beyond proving effectiveness at a macro level for the average participant, we strongly encourage researchers to continue evaluating those mechanisms, pathways, or strategies for improving outcomes that are unique to the three common factors of outdoor therapies, but not while ignoring the factors common to all psychotherapeutic initiatives (i.e., therapeutic alliance, hope, and participant and practitioner factors).

Research beyond therapeutic endeavors is exploring dose effect, health promoting variables (e.g., such as exposure to negative ions and volatile organic compounds), how people can develop their own connection to nature, self-care for healthcare workers, ethics and human rights, and much more [70]. The model of outdoor therapies presented above can be used as a starting point for asking more diverse research questions. Thus, the outdoor therapy community would benefit from practitioner-researchers who can aid in building evidence and knowledge about practice through observational studies, case studies, and explorations of environmental features and outdoor therapy activities.

7. Invitations to the World of Psychotherapy

Returning therapy to the great outdoors does not require climbing ropes, canoes, and backpacks, nor a particularly green thumb. Practitioners are encouraged to reflect on their kinship with nature and examine their anxieties for embracing outdoor therapies. Of course, all therapeutic professionals should practice within their own competencies, and scope or mandate, but outdoor therapies should no longer be viewed as alternative, adjunct, or other-than [71]. If anything, numerous influential voices across the last century of psychotherapy literature appeared to consider their own relationship with nature and how the outdoors could influence change in mental and behavioral health care [72]. There are organizations developing and delivering outdoor therapy training in many forms internationally. Responsibility lies with the practitioner to ensure they are qualified and confident to expand their outdoor practice(s), as well as ensuring client dignity and ethical service [73].

As outdoor therapies continue to evolve and develop, and new approaches emerge, advocates should work together to explore how practitioners can improve their outcomes, refine their theoretical orientations and rationales for the practice, and articulate, document and publish their practice frameworks [74]. While practices continue appearing different and novel on the surface, the common factors remain present in all therapeutic approaches, indoors and out, that contribute the most to outcomes. And for those practicing in nature, being place-based, active and bodily-engaged, and in kinship with nature appear to be the common factors of outdoor therapies.

Author Contributions

NJH and WWD contributed equally to the conceptualization and writing of this manuscript and both authors approved the final manuscript submission.

Competing Interests

The authors declare that this manuscript was written in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.