Walking Therapy: Integrating Movement Into Psychotherapy Sessions

Walking therapy, or "walk-and-talk" therapy, is becoming more popular among mental health professionals and clients. This approach combines traditional psychotherapy with the benefits of walking outdoors.

While the concept may seem straightforward, walking therapy could change how we approach mental health treatment. Taking therapy sessions outside the office can help clients feel less stigma and anxiety than they might in traditional settings.

In this article, we'll look at the growing interest in walking therapy, review the evidence supporting its effectiveness, and offer guidance for mental health professionals who want to include this technique in their practice. Whether you're an experienced clinician or just starting out, walking therapy might open new paths to healing and growth for your clients.

Evidence Base and Clinical Outcomes

Preliminary research on walking therapy shows promising results, especially for trauma-related disorders. A pilot study found that therapists could conduct 67% of trauma-focused sessions while walking, and participants experienced significant reductions in PTSD symptoms (mean decrease of 7.7 points on the PCL-5) and stress levels over 12 weeks.

Studies on exercise-augmented psychotherapy for conditions like depression,  anxiety, and substance use disorders also suggest benefits of walking therapy. However, current research has limitations, such as small sample sizes, weather constraints, predominantly female participants, and a lack of control groups.

Theoretical Mechanisms of Change

Walking therapy suggests several ways for therapeutic change, drawing from biopsychosocial mechanisms:

• Neurobiological Effects: The rhythmic, weight-bearing nature of walking can boost brain-derived neurotrophic factor (BDNF) levels, supporting neuroplasticity and resilience. The changes in blood flow during walking may also improve cerebral perfusion and autonomic regulation, aiding emotional processing and cognitive flexibility.
• Embodied Cognition: The physical act of moving forward while discussing challenges can serve as a strong metaphor for progress and change. Clients might feel a greater sense of control, empowerment, and momentum as they literally take steps towards their goals.
• Therapeutic Alliance: Walking side-by-side can create a collaborative, equal dynamic between therapist and client. Sharing the same environment and navigating the walk together can enhance rapport, trust, and a sense of shared purpose.

Walking therapy also offers valuable opportunities for experiential learning and applying skills. Therapists can guide clients through real-time exercises like mindfulness, grounding, or exposure to feared stimuli, allowing for immediate practice and feedback. The natural environment also provides varied sensory input for self-regulation strategies, such as noticing sights, sounds, or textures to focus attention in the present moment.

As clients build confidence applying coping skills in real-world contexts, they may find greater self-efficacy and resilience. The combination of movement and traditional talk therapy thus offers a comprehensive approach to healing, engaging both mind and body in the process of change.

Client Selection, Contraindications, and Risk Screening

Walking therapy can work well for many clients, but it's important to carefully evaluate potential risks and contraindications. Some clients who might benefit from this approach include:

• Trauma survivors with hyperarousal symptoms: The steady, grounding nature of walking can help regulate the nervous system and provide a sense of safety while addressing traumatic memories.
• Clients struggling with depressive inertia: The physical act of walking can help build momentum and counteract the lethargy and lack of motivation often associated with depression.
• Individuals with anxiety linked to rumination: The sensory input and external focus of walking outdoors can interrupt repetitive negative thoughts and offer a tangible anchor for mindfulness practices.

However, walking therapy may not be suitable for everyone. It's crucial to conduct thorough medical and mobility screenings, such as the Physical Activity Readiness Questionnaire (PAR-Q) or obtaining physician clearance for any cardiovascular concerns. Some contraindications to consider include:

• Severe dissociation or flashbacks: Clients who frequently dissociate or experience intense flashbacks may find the outdoor environment overwhelming or triggering, making it difficult to stay present and engaged in the session.
• Agoraphobia or panic disorders: For individuals with a fear of open spaces or leaving their comfort zone, the prospect of walking outside may provoke excessive anxiety or panic attacks.
• Uncontrolled mania or psychosis: Clients experiencing acute manic or psychotic episodes may struggle to maintain boundaries and safety during a walking session.
• Physical limitations without accessibility options: It's important to ensure that the walking route is accessible and appropriate for clients with mobility issues, chronic pain, or other physical health concerns.

When evaluating clients for walking therapy, it's important to have an open, collaborative discussion about the possible benefits and risks. This conversation should cover topics like confidentiality in public spaces, safety protocols, and any specific concerns the client may have. It's also necessary to obtain informed consent and document the client's agreement to participate in walking sessions as part of their treatment plan.

Practical Implementation Guidelines

When adding walking therapy to your practice, careful planning and preparation are important to ensure a safe, effective, and ethical experience for both you and your clients. Here are some key considerations for implementing walking therapy sessions:

• Route Planning: Choose quiet, well-lit paths with minimal traffic and distractions. Consider the length and difficulty of the route based on your client's fitness level and therapeutic goals. Always have a backup plan for bad weather, such as an alternate indoor location or the option to reschedule.
• Informed Consent Addendum: Develop a specific informed consent document for walking therapy that outlines the unique confidentiality limits and risks associated with conducting sessions in public spaces. This should include a discussion of safety protocols, such as what to do if you encounter someone the client knows, as well as recommendations for appropriate footwear and clothing.
• Session Structure: Start each session with a brief check-in while stationary, reviewing the client's current concerns and setting intentions for the walk. The middle segment of the session can involve walking at a comfortable pace, incorporating therapeutic interventions and skill practice as appropriate. Finish with a seated debrief to process insights, reflect on progress, and take any necessary notes.

To get the most therapeutic benefits from walking sessions, aim for a relaxed, conversational pace that allows for easy dialogue and maintains a sense of safety and connection. Pay attention to your client's nonverbal cues, such as changes in gait or breathing, which may indicate a need to slow down or take a break.

It's also important to be aware of your own physical and emotional boundaries as a therapist. Make sure to wear comfortable, supportive shoes and bring water to stay hydrated. If you find yourself feeling fatigued or overwhelmed, don't hesitate to suggest a rest or modify the route as needed.

Ethical & Legal Considerations

Walking therapy presents unique ethical and legal issues that therapists need to handle with care. Maintaining client privacy is extremely important, especially when sessions occur in public areas. Here are some key strategies to protect confidentiality:

• Choose less crowded paths: Opt for walking routes with fewer people to minimize the chance of others overhearing sensitive conversations.
• Use noise-masking apps: For phone-based walking sessions, consider apps that produce background noise to help keep discussions private.
• Pause conversations when necessary: Stay aware of your surroundings and be ready to stop the conversation if someone gets too close.

Documentation is another important part of ethical walking therapy practice. Be sure to record the client's location, any relevant environmental factors, and potential safety concerns in your session notes. Incorporate movement-based goals and interventions into the client's overall treatment plan to ensure consistent care. 

Maintaining professional boundaries is crucial, as walking therapy can sometimes blur the lines of traditional therapeutic settings. It’s important for the therapist to uphold a professional demeanor throughout the session, even while walking, to ensure the integrity of the therapeutic relationship.

It's also important to check that your malpractice insurance covers services conducted outside the office, like walking therapy. Review your policy thoroughly and talk to your insurance provider to ensure you have adequate liability protection. Update your risk management procedures to address unique considerations for outdoor sessions, such as emergency plans and weather-related issues.

Lastly, clearly communicate with clients about the potential risks and limitations of walking therapy, such as decreased privacy and possible distractions. Obtain informed consent specifically for walking sessions, outlining the steps you will take to protect their confidentiality and safety. By addressing these ethical and legal considerations ahead of time, therapists can set the stage for effective, responsible walking therapy practices.

Troubleshooting Common Barriers

Even with thoughtful planning and preparation, therapists may face various challenges when implementing walking therapy. Here are some common barriers and strategies to tackle them:

• Weather & Seasonal Challenges: Bad weather or extreme temperatures can make outdoor walking sessions uncomfortable or impractical. To address this, consider alternative indoor options like mall walking, indoor tracks, or treadmill-assisted telehealth sessions. Have a clear plan for rescheduling or relocating sessions if the weather doesn't cooperate.
• Client Self-Consciousness: Some clients may feel self-conscious or exposed during walking therapy, especially in public spaces. To ease this discomfort, start with shorter walking sessions and gradually increase the duration as the client becomes more at ease. Opt for less crowded routes or schedule sessions during quieter times, such as early morning. You can also offer a mix of seated and walking portions within a single session.
• Therapist Fatigue/Burnout: Conducting multiple walking therapy sessions in a day can be physically and mentally draining for therapists. To prevent burnout, focus on self-care and set realistic boundaries. Use pacing strategies, such as alternating between walking and seated sessions or taking short breaks between appointments. Stay hydrated and nourished throughout the day, and consider scheduling buffer time to allow for personal reflection and recharging.

Additionally, openly discuss any concerns or challenges with your clients and collaborate on finding solutions that work for both parties. Regularly check in on their comfort level and adjust the walking therapy approach as needed. The aim is to create a safe, supportive, and therapeutic environment that encourages growth and healing, whether inside or outside the office walls.

Measuring Progress & Continuous Quality Improvement

Monitoring client progress is important for assessing how well walking therapy works and improving your practice based on data. Try using a mix of symptom scales, functional metrics, and client feedback to get a full view of treatment outcomes.

• Symptom Scales: Use standardized measures like the PCL-5 for PTSD symptoms or the DASS for depression, anxiety, and stress at regular intervals . These brief self-report questionnaires can help you quantify changes in symptom severity over time.
• Functional Metrics: Encourage clients to track daily step counts, minutes of physical activity, or mood ratings using wearable devices or mobile apps. This objective data from wearable devices (e.g., step counts, heart rate monitoring) can complement subjective symptom reports, offering a fuller picture of how physical activity correlates with emotional and psychological progress in therapy.

Client satisfaction surveys are another important part of continuous quality improvement. Create a brief questionnaire focusing on clients' perceived comfort, therapeutic alliance, and sense of safety during walking sessions. Distribute surveys periodically (e.g., quarterly) and use the feedback to find areas for growth and refinement in your walking therapy program.

Regularly review your walking therapy policies, procedures, and outcomes to ensure you're providing the highest quality care. This may involve adjusting routes based on client feedback, updating informed consent language to address emerging ethical considerations, or incorporating new research findings into your practice.

To stay updated and effective, consider joining professional networks or attending workshops specific to walking therapy. This can help you learn from other practitioners, share best practices, and stay informed about the latest developments in the field.

‍