Journal of Counselor Preparation and Supervision

Volume 15 Number 2 Article 27

2022

The Draw of the Wild: How to Easily Integrate Nature into Clinical
Practice
Jason T. Duffy
SUNY Oswego, [email protected]

Follow this and additional works at: https://digitalcommons.sacredheart.edu/jcps

Part of the Clinical Psychology Commons, Counseling Commons, Counseling Psychology Commons,
and the Health Psychology Commons

Recommended Citation
Duffy, J. T. (2022). The Draw of the Wild: How to Easily Integrate Nature into Clinical Practice. Journal of
Counselor Preparation and Supervision, 15(2). Retrieved from https://digitalcommons.sacredheart.edu/
jcps/vol15/iss2/27

This Article is brought to you for free and open access by DigitalCommons@SHU. It has been accepted for
inclusion in Journal of Counselor Preparation and Supervision by an authorized editor of DigitalCommons@SHU.
For more information, please contact [email protected], [email protected].
The Draw of the Wild: How to Easily Integrate Nature into Clinical Practice

Abstract
For thousands of years many societies and people have intuitively recognized the wellness-enhancing
power of the natural world as well as its ability to assist people in the construction of a sense of purpose
and meaning. More recently, research emanating from the field of ecotherapy as well as other fields has
begun to build empirical support for the efficacy of the natural world in promoting mental and physical
health. This conceptual manuscript provides the rationale for integrating nature into clinical practice and
describes flexible, concise, and easy ways for counselors to utilize ecotherapy in their work with clients,
including, ironically, with the use of technology. A case example is provided to illustrate the utility of this
approach.

Keywords
Nature, Creative Counseling Approaches, Human Development, Eco-therapy, Eco-counseling

Author's Notes
This paper is dedicated to my mom and dad, who taught me to appreciate the beauty and healing powers
of the natural world.

This article is available in Journal of Counselor Preparation and Supervision:

https://digitalcommons.sacredheart.edu/jcps/vol15/iss2/27
 “Everybody needs beauty as well as bread, places to play in and pray in,
where nature may heal and give strength to body and soul.”
-John Muir (Environmentalist and Explorer)

The draw and connection to nature has existed for humans since our first appearance on

earth, a connection that is most likely linked to our biological make-up and reinforced by the fact

that we are inextricably linked to the natural world for food, shelter, and, for many people and

societies, a sense that there are things and matters larger than ourselves. Over the past 200 years,

many societies witnessed large portions of their population disconnect from regular engagement

with the natural world (Kesebir & Kesebir, 2017; Louv, 2015). A 2017 study, The Nature of

Americans National Report, conducted by the Yale School of the Environment that surveyed

12,000 adults in the United States found that it is increasingly normal to spend only a small part

of the day outside (Larson et al., 2019) and went on to find that adults in general are spending less

time in nature than previous generations. Additionally, their research found that school-age

children are spending as much or more time in front of video games and other technology devices

as they do outside. More starkly noted, Americans now spend on average of seven percent of their

days outdoors, a dramatic decrease from prior decades and centuries (Bratman, et al. 2019).

Paralleling this large-scale shift away from engagement with the natural world, mental

health issues such as but not limited to depression, anxiety, existential concerns (e.g., What’s the

purpose to my life? What gives me meaning?), substance use issues, self-harming behaviors, and

suicidal ideation have flourished (Bor et al., 2014). Although some of these adverse conditions and

struggles are due to our increased knowledge, awareness, ability to assess, diagnose and provide

specialized treatment for mental health issues; there is a growing body of research indicating that

there has been a rise in psychological distress for populations in many industrialized nations. For

example, the National Institute of Mental Health (2019) conducted research and found that nearly
one in five adults in the United States suffers from a mental health disorder, making up 18.9% of

all adults. Young adults, categorized as ages 18 to 25, have the highest prevalence of mental health

issues, with nearly one in two (50%) struggling daily with issues such as depression, anxiety, and

other emotional-regulation disorders. Furthermore, a minimum of 2.7% of adults met the full

criteria for Generalized Anxiety Disorder (GAD) over the past 12 months and an estimated 19.1%

met the full criteria for one DSM-5-based anxiety disorder over the past year in the United States

(Harvard Medical, 2017). Although not entirely known yet and captured statistically, the impact of

the societal and cultural changes taking place in the United States and around the world as well as

the worldwide Covid-19 Pandemic are believed to have exacerbated many of the aforementioned

issues. For example, one recent study found a 10 to 20 percent increase in those prescribed mental

health prescriptions in the United States since the start of the Covid-19 Pandemic, which means

one in five Americans (65 million) are now taking mental health medications (CDC, 2021).

Although these statistics are alarming, they most certainly do not capture the complexity

of the problems stemming from the aforementioned societal shift away from nature and elevated

mental health concerns. Statistics fail to fully capture how mental health symptoms associated with

depression, anxiety, and attentional problems have casting and lasting effects on both the

individual and the systems of relationships that surround them and in which they are a part. It is

clear that there is a growing need for approaches to support mental health related concerns in our

society and that need further calls for the ability to meet and support a diverse array of problems

as well as an equally diverse clientele. The purpose of this article is to provide the rationale for

using ecotherapy and to provide specific, concise, and easy activities that therapists can use with

their clients, regardless of the context in which the therapist practices and the client resides.
Additionally, a case example is provided and examined to further illustrate how clinicians may

integrate ecotherapy into their practices.

Counseling and Nature

Many recent studies examining time spent in nature generally indicate improvement in

overall mental health, cognitive functioning, and physical well-being (Buzzell & Chalquist, 2009;

Duffy et al. 2019; Kamitsis & Simmons, 2017). Additionally, research on the use of natural areas

in public locations has indicated that it fosters a sense of connection between people, enhancing

their sense of connection to the outside world, and providing them a sense of purpose and meaning

through this social connectedness (Maller et al., 2009). A branch of psychology known collectively

as Ecopsychology examines the relationship that humans have with the natural environment. At

its core, it seeks to understand and balance people’s relationship with the planet to improve health

and wellness. Ecopsychology findings indicate the need to place value in our relationship to the

natural world (Roszak et al., 1995). A specific offshoot of ecopsychology, loosely termed Eco-

existential Positive Psychology, has a growing body of research indicating that engagement with

the natural world shows measurable increases in subjective measurements of happiness and a sense

of meaning or purpose in life and, conversely, a decrease in perceived social isolation as well as a

decrease in death-related anxiety (Curtin & Heron, 2019). Additionally, the research points to the

rise of industrialization and the shrinking of the world’s natural resources as bringing about some

if not much of the increase in mental health issues. In short, the research indicates that our divorce

from the natural world is causing irreparable harm to humans and the natural world itself (Louv,

2012).

Interest in ecopsychology has increased in recent years and has given rise to the practice

of ecotherapy (Wolsko & Hoyt, 2012). As a modality, ecotherapy seeks to incorporate principles
of ecopsychology into a therapeutic practice (Buzzell & Chalquist, 2009). This form of therapy is

often conducted while being immersed in the natural world but may also include less immersive

activities, such as gardening, meditation in nature, collecting natural objects, guided or self-guided

imagery, and even going for a short walk in the woods or other area that has natural content

(Chalquist, 2009). Clinically, ecotherapy has been shown to aid in treating anxiety, depression, and

stress; as well as improve self-esteem and attentional capacity (Bratman et al., 2015, Kamitsis &

Simmonds, 2017). For example, Wolsko and Hoyt (2012) found that ecotherapy may benefit

individuals dealing with attention-deficit hyperactivity disorder, and may, additionally, foster

increased creativity, an increased sense of identity, and a greater sense of personal meaning in

existence. A recent book edited by Dr. Megan Delaney, Nature is Nurture: Counseling and the

Natural World, provides a detailed rationale and various chapters about using nature in many

different clinical contexts. The bottom line: nature is a versatile tool that has many applications

related to wellness and human development.

Integrating Ecotherapy into Counseling

There are limitless ways counselors can integrate the natural world into their work with

clients. Some of these activities require no natural spaces or nature-based objects and others

necessitate only a minimal amount of nature that can be easily accessed using indoor gardens,

guided imagery activities, plants, images of outdoor settings, and even the use of technology to

recreate the auditory and visual sensations associated with and evoked through engagement with

nature. This section will present a phased process of integrating ecotherapy into the counseling

process.
Phase 1: Psychoeducation on Nature-based Activities

Psychoeducation is a foundational part of many counseling modalities (Bernard &

Goodyear, 2017) and ecotherapy is no different (Scull, 2009). To start this process of integrating

the natural world into the counseling realm, it is important to provide a rationale for its use with

clients and to collaborate with the client on the processes and goals involved (Duncan & Miller,

2000). Typically, discussing the research and anecdotal benefits that have been associated with

time spent in nature (Buzzell & Chalquist, 2009; Louv, 2005; 2012) is a great place to start.

Explaining that this technique will not necessarily replace traditional talk therapy is important, as

some clients may become confused and anxious when they are told -without context- that

counseling may involve activities such as a walk in the woods or mindfully tending to a plant

(Delaney, 2020).

Additionally, most clients already have many memories and emotions connected to the

natural world that they bring into counseling; therefore, there is value in the counselor taking the

time to understand some of the themes attached to these memories. For example, what types of

natural settings has a client experienced? Are the memories largely positive or negative? Do the

memories connect to past trauma? What type of natural setting elicits the most excitement or sense

of calm for a client? When discussing this type of counseling with a class he was teaching, the first

author learned that one of his clinical mental health graduate students was terrified of forested

areas due to the types of insects that may reside there. This student’s fear response emanated from

the experience of living in poverty within a wooded area in a different country as a child and having

been stung and bitten by various insects. Taking the time to explain why and how nature may be a

supplemental part of the counseling experience is extremely important; it is recommended that the
decision to integrate nature be a collaborative enterprise that involves communication between the

client and counselor (Delaney, 2020; Buzzell & Chalquist, 2009).

Phase 2: Picking Nature-based Counseling Activities and Implementation

Once it is collaboratively decided with clients that their issues (e.g., generalized anxiety,

depression, agoraphobia) and therapeutic goals are such that may benefit from the use of

ecotherapy, there are myriad ways to proceed. Typically, starting with a setting or activity that a

client feels familiar with or extremely comfortable trying is recommended (Buzzell & Chalquist,

2009). This process should be collaborative and not simply dictated or organized by the counselor.

Of course, it is important to ensure that the activity is one that is as free as possible of potential

risks to the client (e.g., mental, physical) and involves natural settings that are accessible to the

client (Delaney, 2020). It is important to consider the fact that clients are all different (likes and

dislikes, prior experience, developmental level, cultural background related to nature, and

readiness, etc.) and have different thresholds for novelty, physical exertion, allergic reactions (e.g.,

pollen, bee stings). Therefore, it is important to work with your client collaboratively and,

potentially for minors, have their caretakers/parents connect with their pediatrician or primary care

provider when beginning the activity selection phase. In the following section, a variety of

activities and interventions will be discussed which represent varying approaches; however, there

is no limit to the ways one may integrate nature into the counseling realm. This next section is not

exhaustive but rather seeks to provide some simple and easy to use examples to help counselors

begin to see the numerous possibilities that exist related to ecotherapy.

A Walk in Nature. There is a growing body of research indicating the strong physical and

mental health-related benefits of walking in natural spaces (Bratman et al., 2019). For example, a

study conducted by Song et al. (2018) found that just a short fifteen- to twenty-minute walk in a
natural space (forest, field, grassy area, park, etc.) can boost mental and physical health, lower

blood pressure, decrease rumination on problematic thoughts, and increase a sense of vitality in

people. Some, like Dr. Nooshin Razani, prescribe walks in natural areas as a preventative practice

in their pediatric practices for children and their caregivers to assist in treating emotional

dysregulation issues such as anxiety and panic responses (Razani et al., 2017). One activity that

can either be given to clients as homework or as an in-session supplement -with or without the

counselor- is walking in a natural space. Although discussions related to confidentiality would

need to be included, taking the session outside for part or all of the time can add an invaluable

supplement to other parts of the counseling experience. Making sure clients are comfortable with

this type of technique is important and, as mentioned previously, the ability to maintain

confidentiality is compromised. Although just walking in a natural area is potentially beneficial,

asking clients to connect with their senses (e.g., touch, smell, sound, sight) during the walk may

magnify the benefits of the experience by encouraging clients to enter the here-and-now and full

sensory encounter with the natural world (McGeeney, 2016).

Tending a Small Plant or Garden…Or Even Just Looking at Plants or Gardens. Since

some clients will have limited ability to engage with the natural world on the scale of traversing a

field or forest or sitting next to a running stream, this activity provides a way to encounter nature

that may be more accessible and less time consuming but no less therapeutically meaningful. There

is a growing body of research that indicates that tending to a plant or small garden inside or outside

can promote more positive moods (Soga et al., 2016). In fact, there is research indicating that

people that take a few minutes to look at plants (flowers, shrubbery, trees, etc.) feel more positive

and experience a decrease in anxiety and heartrate (Lim et al., 2020). Many counselors have

intuitively known the benefits of nature and, therefore, adorn their offices with plants (sometimes
permanent botanical renderings glued in pots) because of the perceived connection such objects

have to a sense of calm and relaxation (Delaney, 2020).

Counselors can use this knowledge to create a counseling space that is conducive to the

therapeutic process as well as to provide ways for their clients to garner the benefits of nature

outside of their time in counseling. For example, clients can purchase a small garden box to tend

in their home or can download or purchase a picture of a nature space that they can adorn a wall

within their living space. As with taking walks in natural spaces, counselors can help clients

develop a schedule to engage with a plant, garden, or other forms of natural spaces in a way that

works for them, their lifestyles, and is doable based on time allowances and context.

Going Green with Technology. Although a bit ironic, there are ways to use the power of

technology to assist people in experiencing the benefits of the natural world, especially during

times when the weather or the client’s living situation may be unconducive to nature-based

activities or there are time constraints, etc. Several studies have examined how electronically

produced sounds of nature (thunderstorms, running rivers or creeks, sounds of wildlife in the

forest, etc.) can provide many of the same mental-health benefits as those experienced first-hand

(Gould van Praag et al., 2017; Reynolds, 2018). This type of sound producing technology is now

easily accessible on web-based platforms and sharing options as well as smartphone applications,

and stand-alone sound machines. Taking advantage of the sense of sight, sounds can also be

supplemented by natural settings represented in paintings, pictures, or the plethora of live-stream

and recorded videos on the internet. One recent study in the Journal of Environmental Psychology

examined how watching nature shows on TV (e.g., National Geographic or Discovery Channels)

had a measurable impact on self-reported happiness and motivation. As the lead researcher

described, simply watching nature on television can assist can elevate a person’s mood; a much-
needed mood enhancer for many during the Covid-19 Pandemic (Yeo et al., 2020). The researchers

also believe by extension that the use of virtual technology (e.g., VR goggles) will allow those that

cannot access nature directly (e.g., hospital patients, the elderly) to still reap many of nature’s

benefits.

Guided and Self-guided Imagery. Another approach, one that does not require any

purchases, technology, natural space, or transportation, is the use of guided or self-guided mental

imagery. Guided imagery involves external guidance to allow the internal generation of images,

which invoke visual, auditory, tactile, olfactory and taste experiences (Hart, 2008). Asking a client

to close their eyes and, for example, imagine themselves standing in a field with the warm summer

breeze buffeting their face and smelling the flowering foliage, would be an example of this type

of activity.

This type of approach has been studied and has shown itself to be a robust method for

experiencing the benefits of natural world, and one that can be accessed almost anywhere at any

time (Anxiety and Depression Association of America, 2020; Stein, 2020). Research indicates that

either externally directed (e.g., a recorded voice, an application on a smart phone, a counselor) or

client-directed imaginings of the natural world can produce many of the same benefits as

physically being in and experiencing the natural world (Nguyen & Brymer, 2018; Stein, 2020).

This approach can be a useful tool for clients to learn and utilize on their own when needed outside

of the counseling session. Many clients benefit from this approach being modeled for them and

experienced in counseling prior to trying it on their own.

Phase 3: Reflection, Insight, and Integration

Although there are benefits simply to engaging in nature-based activities like the

aforementioned, there is potential for more to be gleaned from these experiences by using
reflection-based exercises afterwards to assist clients in reflecting on, developing deeper

understanding, and fully integrating the benefits of such activities (Buzzell & Chalquist, 2009;

Duffy et. al 2019). Reflective activities assist individuals in better understanding the nuances of

experiences and assist them integrating novel experiences into their worldview and way of

interacting with the world (Guiffrida, 2015; Mahoney & Granvold, 2005). A few options

emanating from the literature will now be provided in order to illustrate examples or starting off

points for counselors.

Reflective Journaling. Journaling in session or between sessions is an excellent way for

clients to reflect on their nature-based activities. Reflective journal has been used in counseling

and educational settings for decades to promote understanding and meaning making related to

novel experiences and transitional life moments (Hubbs & Brand, 2005; Sutton et. al, 2007).

Therefore, clients may find it beneficial to journal post-ecotherapy experience about their sensory

reactions, thoughts, connections to past experiences, and emotions. Sometimes having clients

sketch images or use more metaphoric ways to express what the experience was like (for example,

creating a collage) can unlock expressive and creative avenues that aren’t as easily accessible using

a straight-forward reflective-journaling approach (Gladding, 2015). Additionally, the counselor

can assist the client in picking themes or topics to journal about related to the experience. For

example, a client can be asked to journal about the question, “How would doing this exercise once

a day for the next year change my life?” or, “How might the daily experience of walking in the

forested area behind my neighborhood impact my sense of priorities in my life?”

Object Associations. Clients may also take a small object from the natural area (e.g., a

stone, a twig, a leaf, a small amount of soil or sand) that can serve as a reminder of the ecotherapy

experiences in general or a specific experience. Using objects as a way to promote certain

emotional states and connect clients to positive past experiences is a technique utilized by various

counseling modalities and supported by research (Kamitsis & Simmonds, 2017). Research

emanating from the field of neuroscience describes objects that elicit memories of past events and

cognitive states as memory cues (Staugaard & Berntsen, 2014). These “objects” can be connected

to any one or a combination of senses: touch, smell, sight, taste, or hearing. These nature-based

objects can provide different ways of connecting to memories during or outside of counseling.

Additionally, this object can be used to help the client return to promote positive emotional states

during times of emotional dysregulation. For example, the client can choose to keep a small pebble

that they picked up during nature walk in their wallet, purse or pocket and touch it or look at it

when they feel emotionally dysregulated. Additionally, a client can close their eyes and smell the

small leaf during a counseling session as a way to promote memories of an ecotherapy event in

order to reflect on it with their counselor.

Pictures and Sounds. Although the use of technology does not have to accompany forays

into nature and other ecotherapy interventions, there are some potential benefits. There is a

growing body of research emanating from various fields indicating that many of the benefits of

engaging with nature can be produced through engagement with nature scenes and sounds on

television, computers, smartphones, sound machines, etc. (Duffy et. al, 2019; Keltner et. al, 2017;).

Therefore, clients, among other things, can take pictures as well as record short videos or sounds

on their smartphones, computers, etc. while in the natural world. For example, after spending time

next to a stream, a client can record the sound of the flowing water on their phone to play back at

a later time in order to re-live or reflect on the earlier experience. Additionally, a client can take a

picture of the town park they just visited as a way to remember the experience. Furthermore, some

research has indicated that watching shows on the nature channel or comparable programming can
bring about an elevated sense of happiness and a cessation or lessening of negative emotional states

(Keltner et. al, 2017). Pictures, videos, and sounds can help clients return to the emotional state

they experienced when engaged with nature and serve to promote further reflection on the

experience (Duffy, in press). Such activities help clients better understand the control they can

exert over their thoughts and emotions as well as behavior.

A Case Example

In compliance with the American Counseling Association 2014 Code of Ethics, identifying

information was obscured and or changed in the following case study. This author encountered a

43-year-old woman, Angela (pseudonym and some information changed to protect client

identification), who entered counseling due to issues stemming from lifestyle changes related to

the COVID-19 pandemic. Prior to the pandemic, Angela described herself as “hardworking”,

“happy”, and “usually easygoing.” Angela previously cited feeling “mostly balanced” between the

needs and expectations of her job, her family, and described self-care as an essential part of her

life. In her early twenties, Angela engaged briefly with a talk therapist and, through that experience,

was able to develop increased self-awareness and coping skills related to stress management and

the reduction of anxiety related symptoms. Angela cites working out at the gym and spending time

with friends and family being beneficial strategies she has utilized to maintain the balance she once

felt. Angela entered into therapy one month into the COVID-19 pandemic after she began working

full time from home while caring for her two school aged children (ages seven and 11) and

facilitating their distance learning. Angela reported an increase of anxiety symptoms, including

ruminating thoughts, disturbance to sleep, and irritability, especially with her children. Angela

indicated that due to the pandemic and social distancing protocols, she has been unable to draw

from her previous and helpful coping strategies of working out at the gym and spending quality
time with extended family and friends. Angela brought up her symptoms and concerns while in a

tele-medicine visit with her primary care provider, and the provider encouraged her to consider

counseling before engaging in an acute psychotropic medication trial to support her anxiety

symptoms and sleep disturbance. During initial sessions, Angela articulated that she was struggling

to find purpose and to feel comfortable with the changes surrounding working from home and the

stress related to increased household responsibilities. These factors coupled with the reduced

access to her extended support system and limited options to self-regulate and destress through her

preferred method of working out at the gym, left Angela feeling increasingly irritable, less engaged

in her work-related projects, and feeling resentment and a decreased ability to, in her words, “feel

present with my family”.

Case Study Phase One: Psychoeducation on Nature-based Activities

After isolating the major “stressor” areas that appeared to precipitate the symptoms, the

second author worked with Angela to go over confidentiality and then create a plan utilizing

nature-based intervention and activities to aid in the reduction of her adjustment and anxiety related

symptoms. Angela described herself as an indoor person who can appreciate nature, but due to her

upbringing and present lifestyle, has not had ample opportunity to engage with nature on a

meaningful or pronounced level. Angela and the author broke the time and interventions into four

categories to incorporate nature-based therapy. First: Bringing nature indoors into her workspace.

Second: Incorporating outdoor time for Angela to engage deeper and intentionally with her

surroundings. Third: A component where Angela utilizes nature-based activity with her children.

Fourth: Angela was encouraged to journal her experience and she went on to decide to take time

in therapy to share out and process some of the emotions and themes that came out of her writings.
Case Study Phase Two: Picking Nature-based Counseling Activities and Implementation

After developing a plan to integrate nature into her life for therapeutic purposes, Angela

began by redesigning her home-work space to include natural elements as a way to enhance her

experience and wellbeing. Angela moved her workspace from the main living quarters of her

apartment to a more private space inside her bedroom. She positioned her desk and laptop facing

a window that overlooks a maple tree in the greenspace of her apartment building. After the desk

move, Angela reports an increased sense of peace when gazing out the window between tasks.

Additionally, Angela reports feeling an increased connection to her surrounding and the outdoors.

Angela indicates this is stemming from her ability to feel “grounded” by observing the same tree

change throughout the day due to lighting, weather, and seasons. Never previously a bird watcher,

Angela indicates a newfound interest after observing a robins’ nest in the tree outside her window.

She does mention the hatchlings can be rather loud sometimes.

In addition to moving her desk, Angela was encouraged to select images of natural settings

that she placed on the walls surrounding her workspace. While in counseling session, Angela and

the author processed pleasurable and nature-based childhood experiences that Angela was able to

recall. Based upon this exploration, Angela went on to select various images of waterfalls and

forest creeks that she printed and affixed to the walls surrounding her workspace. To enhance the

sensory experience, Angela incorporated listening to a recording of flowing water. Throughout the

therapeutic intervention, Angela reports feeling an increased sense of calm while listening to the

recording of flowing water while she focused on the printed-out images and her window

overlooking the maple tree. Angela was able to draw meaningful connections between feeling, in

her words, “open, relaxed, and at peace” within her home.

 Angela also began taking fifteen-minute outdoor breaks twice a day during the time she

was working from home and caring for her children. The concept of a “sit spot” was discussed

while in session, and Angela was enthusiastic to try to engage with her outdoor environment by

sitting quietly, free from judgment, while taking note of physical and emotional sensations and

changes she may feel throughout the nature-based immersion activity. Angela began by sitting

under the maple tree that faced her apartment building. Angela engaged in a free-write journaling

exercise during her outdoor sessions. During the journaling process, Angela took time to note her

anxiety symptoms pre-outdoors, and post-outdoors. Notable themes that came up included a desire

for stillness, a desire for connection, and increased feelings of gratitude. Angela was able to process

her nature immersion experience in her counseling sessions and drew meaning from the experience

that led to deeper awareness of her own desires to appreciate being in the present moment and

surrounding herself with nature.

Encouraged by the newly found peace and reduction of her own anxiety-related symptoms,

Angela began involving her children in some of the nature based therapeutic interventions that she

had found beneficial. Angela encouraged her children to go through family pictures of past outdoor

experiences they shared together. She printed copies and affixed them to the space surrounding her

children’s distance learning workspaces within their apartment. Angela began going on, what she

referred to as, “quiet walks” with her children in the afternoons. Prior to engaging in nature in a

therapeutic level, Angela indicates that outdoor time with her children was previously just group

sport and free play. By incorporating the quiet walks with her children, Angela reports feeling more

connected to her children as well a newfound appreciation for slowing down and engaging in the

outdoor space around them.

Case Study Phase Three: Reflection, Insight and Integration

At one point in session, Angela indicated that she was surprised such small changes to her

lifestyle could have led to a reduction of her anxiety, depressive, and motivation-related symptoms.

During the day, Angela indicates her workspace feels more comfortable, and she has been able to

remain on task and productive after taking fifteen-minute breaks under the maple tree beside her

apartment building. Angela reported that her sleep disturbances have improved after utilizing the

recording of the flowing water in times of restlessness and unease preceding sleep. While Angela

continued to struggle with the some of the changes she experienced due the COVID-19 pandemic,

her attitude toward her experience evolved: she acknowledged that her need for peace and stillness

was justified, and she had the ability to modify her own experiences in slight ways to improve her

overall functioning and wellness.

Practice Considerations

Just like any counseling modality or intervention, careful attention must be taken to ensure

it is an appropriate approach for the client (s), is ethically and contextually sound, and is

empirically supported (ACA, 2014). Some clients may have experienced adverse experiences in

nature or view ecotherapy unfavorably for myriad reasons. Also, does the client have physical

limitations based on differing abilities or current health that must be considered when making

decisions about whether they may or may not engage with the natural world. Additionally, the

contemporary approach to counseling is conceptualized as a collaborative process between client

and counselor and, therefore, the decision to use this modality or to supplement another modality

with ecotherapy interventions should be considered collaboratively with the client or, in the case

of minors, with their caregivers (ACA, 2014). Appropriate steps also must be taken to ensure that

safety is considered when utilizing ecotherapy. For example, how much experience does a client
have engaging with nature? Does a client have allergies that may be triggered by certain plants or

animals? Is the natural environment that is accessible to the client a safe place for a client to walk,

sit, etc.? Many times, the first author of this article will ask the client to provide documentation

from a primary care provider or pediatrician if a nature-based intervention requires any type of

physical exertion (e.g., walking outdoors / hiking). At the very least, securing consent from the

client and documenting it is recommended. As with any modality or intervention, the idiosyncratic

contextual variables should be assessed before proceeding and consistent evaluation of the

intervention (s) by the counselor and client and the necessary recalibration of treatment should

take place.

A concern often raised by counselors and many that supervise counseling students and

counselors when considering the use of ecotherapy is maintaining client confidentiality. As

mentioned previously, there are many ways to integrate nature into counseling that do not involve

leaving the typical counseling space. The use of small plants, natural scents, pictures, nature

sounds, visualization, virtual reality and video streaming, etc. allows counselors to tailor the

interventions they use to the needs of each client as well as the context in which the counseling

takes place and the client lives. Although confidentiality is considered an important aspect of

counseling, some clients will accept potential exposure to other people in order to directly engage

nature in an outdoor counseling setting. To accomplish this, many counselors have clients sign

consents to engage in ecotherapy, especially if the client is accompanied by the counselor during

the intervention. For example, the consent used by the first author of this article includes the

following two statements: (a) I understand that if my counselor and I come into contact with a

person that I know, I have the right to disclose or not to disclose that I am in a counseling session.

I understand that my counselor will follow my lead should we come into contact with a person I
know and my counselor will make every effort to preserve client confidentiality and privacy while

conducting my nature-based counseling session; and (b) I understand that if my counselor should

come into contact with a person he/she knows, my counselor will not acknowledge me as a client

or the outdoor counseling session as counseling to preserve confidentiality. Of course, all

counselors should of course check with their malpractice insurance and local laws and ordinances

to ensure that they are providing counseling in an ethical manner.

Thinking about all the possible interventions when incorporating nature into their work as

well as the idiosyncrasies of the client provides counselors the ability to work with people with

varying amounts of nature experience, levels of comfort with nature, and differing levels and types

of nature (e.g., small park, pond, communal garden, fields) in their immediate environment.

Perhaps a client is highly anxious about engaging in a trail walk through a sprawling forest and

would rather just listen to the sound of thunder and rain emanating from a sound machine or sound

application on a smart phone. The myriad options of integrating nature into counseling provides

options for all clients, including those that are differently abled. For example, if a client struggles

to or is unable to walk, perhaps a smart-phone-based virtual reality experience is utilized. If a client

has decreased visual acuity, perhaps an activity involving visualization, sounds, and scents is

appropriate. The bottom line is that there are limitless ways to easily integrate nature into the

counseling realm, and we are only limited by ours and our client’s imagination in terms of how we

may do so.

Conclusion

Although many people and societies have intuitively and anecdotally known that the

natural world can promote wellness, it has only been in the last two decades that researchers have

begun to add empirical support as well. This evidence has allowed informed mental health
practitioners and other health-care workers to integrate nature-based interventions more

confidently into their practices; however, there is still a dearth of literature that is easily accessible,

concise, and readable for practitioners which provides the rationale, evidence, and various specific

ways health practitioners can begin to integrate the natural world into their work. This article is an

attempt to fill that gap along with the small but growing literature base coming from other eco-

based wellness pioneers. Clearly, more research is needed in relation to the use of nature to promote

wellness, especially related to specific diagnoses and medical conditions. However, it is now clear:

nature is a powerful ally of health care providers and is accessible in myriad ways.
 References

American Counseling Association. (2014). 2014 ACA code of

ethics. https://www.counseling.org/docs/default-source/default-document-library/2014-
code-of-ethics-finaladdress.pdf
Anxiety and Depression Association of America (2020). Coronavirus anxiety - helpful
tips and expert resources. https://adaa.org/finding-help/coronavirus-anxiety-helpful-
resources
Bratman, G. N., Anderson, C. B., Berman, M. G., Cochran, B., de Vries, S., Flanders, J., Folke,
C., Frumkin, H., Gross, J. J., Hartig, T., Kahn, P. H., Jr, Kuo, M., Lawler, J. J., Levin, P.
S., Lindahl, T., Meyer-Lindenberg, A., Mitchell, R., Ouyang, Z., Roe, J., … Daily, G. C.
(2019). Nature and mental health: An ecosystem service perspective. Science
Advances, 5(7), eaax0903. https://doi.org/10.1126/sciadv.aax0903
Bor, W., Dean, A. J., Najman, J., & Hayatbakhsh, R. (2014). Are child and adolescent mental
health problems increasing in the 21st century? A systematic review. Australian & New
Zealand Journal of Psychiatry, 48(7), 606–
616. https://doi.org/10.1177/0004867414533834
Buzzell, L., & Chalquist, C. (2010). Ecotherapy: Healing with nature in mind. Catapult.
Curtin, S., & Heron, M. (2019, October). Death rates due to suicide and homicide among
persons aged 10-24: United States, 2000-2017.
https://www.ncbi.nlm.nih.gov/pubmed/31751202
Curtin, S., Warner, M., & Hedegaard, H. (2016, April). Increase in suicide in the United States,
1999-2014. https://www.ncbi.nlm.nih.gov/pubmed/27111185
Delaney, M. (2020). Nature is nurture: Counseling in the Natural World. Oxford University
Press.
Duffy, J. T., Springer, S., Delaney, M. & Luke, M. (2019). Eco-counselor education: Using
nature in the counseling classroom. Journal of Creativity in Mental Health, 15(1), 55-68.
https://doi.org/10.1080/15401383.2019.1640152
Duffy, J. T. (Accepted). The draw of the wild: Improving mental health through nature. Journal
of Counseling Supervision and Education.
Duncan, B. L., & Miller, S. D. (2000). The client’s theory of change: Consulting the client in the
integrative process. Journal of Psychotherapy Integration, 10(2), 169-187.
https://doi.org/10.1023/A:1009448200244
Federico F. (2020). Natural Environment and Social Relationship in the Development of
Attentional Network. Frontiers in Psychology, 11, 1345.
https://doi.org/10.3389/fpsyg.2020.01345
Franco, L. S., Shanahan, D. F., & Fuller, R. A. (2017). A review of the benefits of nature
experiences: More than meets the eye. International Journal of Environmental Research
and Public Health, 14(8), 864. https://doi.org/10.3390/ijerph14080864
Freud, S. (1938). Totem and taboo: Resemblances between the psychic lives of savages and
neurotics. Penguin Books.
Gladding, S. (2016). The creative arts in counseling: Fifth edition. American Counseling
Association.
Gould van Praag, C., Garfinkel, S., Sparasci, O., Mees, A., Philippides, A., Ware, M., Ottaviani,
C., Critchley, H. (2017, March 27). Mind-wandering and alterations to default mode
network connectivity when listening to naturalistic versus artificial sounds.
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5366899/
Guiffrida, D. (2015). A Constructive Approach to Counseling and Psychotherapy Supervision,
Journal of Constructivist Psychology, 28(1), 40-52,
https://doi.org/10.1080/10720537.2014.922911
Hart J. (2008). Guided imagery. Alternative complementary therapies, 14(6), 295–299.
https://doi.org/10.1089/act.2008.14604
Harvard Medical School (2007). National Comorbidity Survey (NCS). (2017, August 21).
https://www.hcp.med.harvard.edu/ncs/index.php.Data
Hubbs, D. L., & Brand, C. F. (2005). The paper mirror: Understanding reflective journaling.
Journal of Experiential Education, 28(1), 60-71.
https://doi.org/10.1177%2F105382590502800107
Kamitsis, I., & Simmonds, J. (2017). Using resources of nature in the counselling
room: Qualitative research into ecotherapy practice. International Journal for the
Advancement of Counselling, 39(1). https://doi.org/10.1007/s10447-017-9294-y
Keltner, D., Bowman, R., & Richards, H. (2017). Exploring the emotional state of ‘real happiness’.
A study into the effects of watching natural history television content. https://asset-
manager.bbcchannels.com/workspace/uploads/bbcw-real-happiness-white-paper-final-
v2-58ac1df7.pdf
Kesebir, S., & Kesebir, P. (2017). How modern life became disconnected from nature.
https://greatergood.berkeley.edu/article/item/how_modern_life_became_disconnected_fr
om_nature
Larson L. R., Szczytko R., Bowers E. P., Stephens L. E., Stevenson K. T., & Floyd M. F. (2019).
Outdoor time, screen time, and connection to nature: Troubling trends among rural
youth. Environment and Behavior, 51(8), 966-991. https://doi.org/10.1177%2F00139165
18806686
Lim, P. Y., Dillon, D., & Chew, P. (2020). A guide to nature immersion: Psychological and
physiological benefits. International Journal of Environmental Research and Public
Health, 17(16), 5989. https://doi.org/10.3390/ijerph17165989
Louv, R. (2005). Last child in the woods: Saving our children from nature-deficit disorder.
Algnonquin Books of Chapel Hill.
Louv, R. (2012). The nature principle: Reconnecting with life in a virtual age. Algnonquin
Books of Chapel Hill.
Mahoney, M. J., & Granvold, D. K. (2005). Constructivism and psychotherapy. World
Psychiatry: Official Journal of the World Psychiatric Association (WPA), 4(2), 74–77.
McGeeney, A. (2016). With nature in mind: The ecotherapy manual for mental health
professionals. Jessica Kingsley Publishers.
Nguyen, J., & Brymer, E. (2018). Nature-Based Guided Imagery as an Intervention for State
Anxiety. Frontiers in Psychology, 9, 18-58. https://doi.org/10.3389/fpsyg.2018.01858
Reynolds, C. (9, Jan. 2018). Buxton quoted in Reader Digest article on sleep sounds. Penn State
Social Science Research Institute. https://www.ssri.psu.edu/news/2367/buxton-quoted-
reader-digest-article-sleep-sounds
Scull, J. (2009). Tailoring nature therapy to the client. In L. Buzzell & C. Chalquist's (Eds.),
Ecotherapy: Healing with nature in mind (pp. 140-148). Sierra Club Books.
Soga, M., Gaston, K. J., & Yamaura, Y. (2016). Gardening is beneficial for health: A meta-
analysis. Preventive Medicine Reports, 5, 92–99.
https://doi.org/10.1016/j.pmedr.2016.11.007
Song, C., Ikei, H., Park, B.-J., Lee, J., Kagawa, T., & Miyazaki, Y. (2018). Psychological benefits
of walking through forest areas. International Journal of Environmental Research and
Public Health, 15, 2804. https://doi.org/10.3390/ijerph15122804
Staugaard, S. R., & Berntsen, D. (2014). Involuntary memories of emotional scenes: the effects
of cue discriminability and emotion over time. Journal of Experimental Psychology
General, 143(5), 1939–1957. https://doi.org/10.1037/a0037185
Stein, D. (2020, March 10). Nature imagery may alleviate anxiety.
https://www.psychologytoday.com/us/blog/the-integrationist/202003/nature-
imagery-may-alleviate-anxiety
Sutton, L., Townend, M., & Wright, J. (2007). The experiences of reflective learning journals by
cognitive behavioural psychotherapy students. Reflective Practice: International and
Multidisciplinary Perspectives, 8(3), 387-404.
https://doi.org/10.1080/14623940701425048
Razani, N., Loudin, A., Prelle, M., & Staff, R. (2017, September 05). Prescribing nature for
health. https://www.rei.com/blog/fitness/prescribing-nature-for-health
Thompson, D. (2019, October 07). Three decades ago, America lost its religion. Why?
https://www.theatlantic.com/ideas/archive/2019/09/atheism-fastest-growing-religion-
us/598843/
Yeo, N., White, M., Alcock, I., Garside, R., Dean, S., Smalley, A., & Gatersleben, B. (2020).
What is the best way of delivering virtual nature for improving mood? An experimental
comparison of high-definition TV, 360° video, and computer-generated virtual
reality. Journal of Environmental Psychology, 72, 101500.
https://doi.org/10.1016/j.jenvp.2020.101500