Background

The therapeutic value of contact with nature is of growing interest to researchers (Frumkin et al 2017). Outdoor, nature-based therapeutic interventions are considered to hold wide-ranging physical and mental health benefits and have significantly grown in number and type in recent years (Moeller et al 2018, Cooley et al 2021). Outdoor therapies are highly diverse in format and processes, but contact with nature is an essential component (Harper et al 2021).

Severe and enduring mental health issues can be described as a group of conditions that are often chronic and so debilitating that they severely impair people’s ability to engage in functional and occupational activities (Office for Health Improvement and Disparities 2023). People with severe and enduring mental health issues are at greater risk of physical health issues and tend to die 20 years earlier than the general population (Office for Health Improvement and Disparities 2023, Parker et al 2023). This is largely attributed to physical health conditions related to increased body weight, hypertension, dyslipidaemia and insulin resistance, which antipsychotics, often prescribed to people in this group, may exacerbate (Schnor et al 2019).

Exposure to or contact with nature has been shown to have physical and mental health benefits, including reduced blood pressure and heart rate, lower incidence of diabetes mellitus, reduced cardiovascular and all-cause mortality (Twohig-Bennett and Jones 2018), enhanced mental well-being (McMahan and Estes 2015, Yao et al 2021), reduced stress levels, improved sleep and reduced symptoms of depression and anxiety (Coventry et al 2021, Olcoń et al 2023). Therefore, outdoors therapies are relevant when working with people with severe and enduring mental health issues (Hartley et al 2013, Faulkner and Bee 2016).

Engaging in therapeutic work outdoors offers an alternative for patients who find indoor sessions too formal, intimidating and/or anxiety provoking (Jordan and Marshall 2010, Cooley and Robertson 2020). Outdoor clinical sessions enable people to process their thoughts and emotions non-verbally (Adevi et al 2018), give them a greater sense of ownership of the sessions and provide an escape from daily routines and environments (Cooley et al 2020). These factors are important when working with people with severe and enduring mental health issues, as research has shown that it can be challenging to engage them in longer-term interventions (Dixon et al 2016, Melamed et al 2019).

The British Psychological Society (Cooley and Robertson 2020) and Leicestershire Partnership NHS Trust (Crossley et al 2022) recommended evaluating the effects of outdoor therapeutic work to help address the lack of research in this area (Cooley et al 2020). James et al (2021) explored the perspectives of service users and clinical psychologists in inpatient rehabilitation units within Leicestershire Partnership NHS Trust on the feasibility of outdoor psychology sessions. The researchers found such sessions decreased distress, increased sense of freedom and made service users feel more comfortable talking to psychologists, and concluded that ‘outdoor sessions can be an effective and safe mode of therapy, and can offset the challenges of working indoors, providing certain risk factors are considered and managed’.

This article details a service evaluation undertaken in Leicestershire Partnership NHS Trust to expand the evidence base and to consider whether James et al’s (2021) findings apply to community rehabilitation settings. This service evaluation considered the perspectives of a wider range of professional disciplines and roles than James et al (2021) and expanded the definition of ‘outdoor session’ beyond nature settings and green spaces.

Aim

To explore the perspectives of service users and staff in an adult mental health community rehabilitation setting on outdoor clinical sessions.

Method

Recruitment and data collection

Recruitment and data collection was undertaken in May-July 2023 by two assistant psychologists (the first and third authors of this article) who were not involved in clinical care.

Service users with an open referral to the CERT during the data collection period were approached and invited to participate. Service users were not approached if the multidisciplinary team (MDT) deemed it inappropriate to do so, if they were not discussed in MDT meetings during the data collection period or if they were inpatients. Service users could participate over the phone – which 95% chose to do – or face to face.

Service users who agreed to participate (n=19, 12 men, 7 women) completed a questionnaire comprising three yes/no questions with space for additional comments (Figure 1). An additional question following completion of the questionnaire asked participants to confirm if they had experience of outdoor sessions. Those who said they had experienced outdoor sessions were then asked to take part in a semi-structured interview containing seven questions and/or complete the Session Rating Scale (SRS) V3.0 (Miller et al 2000). The SRS is designed to measure three domains of the therapeutic alliance – ‘relationship’, ‘goals and topics’ and ‘approach/method’ – and is intended as a visual scale. There is a 10cm line between two statements for each domain; the person marks a point along the line, between 0 and 10, to rate their experience. As this part of the service evaluation was undertaken over the phone, the researcher read each statement to the participant and asked them to verbally rate it on a scale of 0-10; for example, for the relationship domain the statement on the left side of the scale was ‘I did not feel heard, understood and respected’ and the statement on the right side of the scale was ‘I felt heard, understood and respected’. James et al (2021) used the SRS with an additional domain, designed to ‘assess how comfortable/uncomfortable service users felt outdoors’ and this was included in the present service evaluation.

Figure 1.

Service users’ (n =19) responses to the questionnaire

Key points

• • Being outdoors can facilitate conversations and allow time away from the usual environment

• • Anxieties triggered by the idea of participating in outdoor sessions may resolve once the person is taking part in them

• • Being outdoors may be an intervention in itself, helping to reduce anxiety, increase confidence and reconnect with the community

• • Staff should ensure that outdoor sessions remain person centred

Of the 19 participants who completed the questionnaire, 12 took part in an interview (8 men, 4 women) and ten completed the SRS (5 men, 5 women). Participants’ ages ranged from 18-74 years.

The two assistant psychologists also invited CERT staff, who were not part of the team undertaking the evaluation (n=17), to take part in an interview. Ten CERT staff agreed to participate (1 clinical psychologist, 3 trainee psychologists, 1 assistant psychologist, 2 nurses who were also part of management, 2 occupational therapists, 1 healthcare support worker).

Interviews with staff were semi-structured and contained ten questions; nine of the interviews were conducted via a digital communication platform.

Before each interview, the definition of ‘outdoor session’ used in the evaluation – ‘anywhere outside of your typical therapy space, such as the service user’s home, a hospital or GP surgery. This might include sessions conducted outdoors, on public transport or in community buildings such as shops’ – was read to the participant.

Quantitative findings

Qualitative findings

The following themes and subthemes emerged from analysis of the qualitative data:

Discussion

Similarly to previous research, such as Cooley et al (2020) and Harper et al (2021), this service evaluation identified wide-ranging benefits of outdoor clinical sessions. The SRS responses showed that most service users were interested in working outdoors, with outdoor sessions rated highly across SRS domains.

Harper et al (2021) discussed contact with nature as an essential component of outdoor therapy. In the present evaluation, the definition of ‘outdoors’ was expanded to include anywhere outside typical therapy spaces, since service users’ goal of community reintegration may not always include being in nature. Benefits of outdoor sessions for mental and physical health were shown, which confirms previous research such as Cooley et al (2021), who suggested that both nature and urban walks produced various health benefits. This extends the scope for community services to provide outdoor sessions for people who live far from natural green spaces.

Common findings between the present evaluation and James et al (2021) included that being outdoors facilitated conversations and allowed time away from the usual environment, the challenges of managing confidentiality and the benefits of outdoor sessions for physical health. Some findings were specific to this evaluation, which may reflect the community setting but also suggests that there are unique benefits of outdoor sessions for service users living in the community.

The outside environment appeared to have several advantages, including facilitating conversations and benefiting mental and physical health. The idea of communication being easier outdoors is supported by research showing that outdoor sessions are a useful alternative for service users who find indoor appointments too formal and clinical (Jordan and Marshall 2010, Cooley et al 2020). However, the lowest-rated SRS domain in the present evaluation was ‘goals and topics’, which suggests that staff should ensure that outdoor sessions remain person-centred; this could also mitigate confidentiality issues by giving service users more control over the conversation.

Many service users had had their first outdoor sessions more than one year before the service evaluation and had continued to engage in these sessions and described them positively. Outdoor sessions may therefore offer a way of engaging people with severe and enduring mental health issues in longer-term interventions, which can often be difficult (Dixon et al 2016). The positive effects on mental well-being and physical health found in the present evaluation confirm previous research, such as McMahan and Estes (2015), Twohig-Bennett and Jones (2018) and Yao et al (2021).

Concerns mentioned by service users in the questionnaire were rarely discussed in the interviews, which could suggest that the anxieties triggered by the idea of participating in outdoor sessions resolve once the person is taking part in them. However, on the SRS the ‘outdoors’ domain was the second lowest rated. This may be because the environment in outdoor sessions is new to service users, which demonstrates the importance of discussing with service users what they can expect from such sessions.

Being outdoors appeared to be an intervention in itself, helping to reduce anxiety, increase confidence and reconnect with the community. This confirms findings by Olcoń et al (2023), who noted that outdoor interventions decreased anxiety and increased confidence in interacting with others, and by Coventry et al (2021), who found ‘large and significant effects’ of outdoor interventions on reducing anxiety. The fact that outdoor sessions appear to enable community reintegration is important, as this is a key goal of the CERT service.

Most comments on the difficulties of outdoor working came from staff. Information about the outdoor spaces and activities available should be shared among staff to reduce preparation time. Staff should be offered training, particularly on how to manage confidentiality issues when outdoors. However, there are benefits of working outdoors for staff, such as not being between ‘four walls’. Cooley et al (2020) suggested that working outdoors can help combat the high levels of staff burnout seen in the NHS.

Recommendations in the ‘unpredictability’ and ‘making improvements’ themes included developing a hybrid model combining indoor and outdoor working, given the issues with weather, access and confidentiality. This would ensure that fewer appointments are cancelled, all necessary conversations can take place and sessions better suited to indoor working, for example, paperwork or family therapy, remain possible. In addition, outdoor sessions should be diverse, offered to service users early in their contact with community teams and allocated enough time so that neither staff nor service users feel rushed.

Conclusion

This service evaluation in a mental health community rehabilitation setting explored service user and staff perspectives on outdoor clinical sessions. It adds to the nascent evidence on outdoor therapy interventions and confirms their wide-ranging physical and mental health benefits for service users and staff.

The findings suggest that outdoor sessions support service users on their journey towards community reintegration and offer a way of engaging people with severe and enduring mental health issues in longer-term interventions. The findings encourage continuation of outdoor sessions with service users supported by CERT staff, but also indicate that sessions should be given further thought and resources.