Amid the pandemic, could the great outdoors become the new psychotherapy office for patients who need in-person mental treatment?

Jami Grich, a psychologist in San Francisco, definitely thinks so. Several months ago she set up space in her backyard to see people. “With small kids at home, I needed to find a way to meet patients face-to-face. My backyard was the perfect solution because it’s spacious and easy to maintain social distance,” she says.

Due to the novel coronavirus, many mental health providers, like many other medical professionals, are conducting therapy remotely. While research shows teletherapy can help treat anxiety and depression, virtual meetings don’t work for everyone. I’m a therapist and it can be challenging to observe patients’ nonverbal behaviors or convey empathy via Zoom. When someone cries, for instance, it can be helpful to hand them a tissue — teletherapy disrupts this simple in-person expression of care.

Tania Paredes, a bereavement therapist in Miami, counsels grieving parents. As part of her work, she now offers “walk-and-talk” therapy. “Bodily movement,” she says, “can help families reflect and open up about their loss.” At a time when mourning rituals — such as funerals, wakes or sitting shiva — are strongly discouraged, this connection can be a lifeline. One patient told Paredes that “walking and talking helped her move through her grief.”

Outdoor therapy is practiced elsewhere in the world and has been shown to be helpful.

In Zimbabwe, peer counselors called “community grandmothers” counsel women on park benches called “friendship benches.” A 2017 study found that “friendship bench counseling” in that country helped women recover from depression, anxiety and trauma. In addition, a nature-based therapy called “Forest Bathing” has been found to lower stress, boost the immune system and reduce anxiety.

Since 2018, San Francisco Bay area therapists Adam Moss and Nathan Greene have led a surf therapy group for teen boys who struggle with family issues, relationship concerns and anxiety. Moss and Greene teach the teens how to ride the ocean waves and read the water’s currents. “Surfing requires the guys to challenge themselves and learn their limits,” Greene says. After the lesson, the boys gather on the beach and share their experiences with one another. One group member told Moss and Greene, “The ocean, like life, is powerful and unpredictable.”

As a therapeutic approach, “early research suggests outdoor therapy is effective,” says clinical psychologist C. Vaile Wright, the senior director of Health Care Innovation in the Practice Directorate at the American Psychological Association. She adds that “research suggests outdoor therapy can also be useful for kids and adolescents diagnosed with” attention-deficit/hyperactivity disorder.

Stefanie Haug, a family therapist in Cambridge, Mass., says remote therapy, via the phone or video, doesn’t always benefit a child or their family’s well-being. “Because kids spend hours in front of a screen, many of them find it hard to stay present, focused and connected during teletherapy sessions,” she says.

To deal with that, Haug meets children and their parents in their backyard or at a local park. Being outdoors sparks creativity, which can help children feel more engaged. “I’ve had sessions on swing-sets and played bocce ball with some of my patients,” Haug says.

Haug says doing outdoor therapy session has also bolstered her own well-being. “Outdoor sessions have rejuvenated my energy and enthusiasm for my work. I imagine continuing during the winter months,” she explains. Working with children, it’s easy to incorporate nature into play therapy. “When it snows, making a snowperson together could be a great way for kids to discuss goal setting,” Haug says.

Of course, holding a session outdoors does have pitfalls that patients need to know about. “Confidentiality can be compromised because the conversation may be overheard,” Wright says. And patients have to be warned that covid-19, the disease caused by the coronavirus, can be transmitted even outdoors so that safety precautions such as mask-wearing and social distancing must be taken.

Patients without privacy at home or Internet access present special challenges. When it comes to successful therapy, the therapeutic relationship matters most, research shows. If teletherapy hinders the patient’s recovery, meeting in person should be considered, the APA says.

From the start of the pandemic until September, Moss and Greene held their “surf therapy group” on Zoom due to the pandemic. But certain aspects of the experience couldn’t be replicated online. “The guys missed the healing powers of nature and being together in person,” Moss says.

After speaking with the group and their parents, the therapists decided to resume socially distanced meetings on the beach.

“We began by standing in the knee-deep water of the ocean. Then we sat on the beach (six feet apart) and reflected on the strangeness of the pandemic,” Moss says in an email. Several group members expressed their feelings of sadness and isolation and the group members felt a sense of closeness and community from each other.

Since winter weather in the Bay Area is mild, Moss, Greene, and Grich can continue conducting outdoor sessions as long as it’s safe to do so. Outdoor therapists who practice on the East coast or in the Midwest, however, face different decisions that will hit soon — if not already — now that temperatures are starting to fall. If weather allows, therapists like Haug say they may still try to hold outdoor sessions. Other therapists say they are undecided about whether they’ll resume video sessions as the weather gets colder and darker.

Sam Nabil, a therapist in Boston who works with adults, has been offering “walk-and-talk” therapy since April. But a recent spike in covid-19, and the growing darkness and dropping temperatures, has him now preparing to go back to remote sessions for the winter months.

While conducting therapy in public spaces has pros and cons, therapists say they seem to be a hit with those needing therapy. “One patient said it was ‘uplifting’ to walk outside,” Nabil says.

Stephanie Korpal, a psychotherapist in St. Louis who works primarily with new mothers, says meeting patients for walks has added a sense of “normalcy” to their lives.

“Many postpartum moms say that seeing another adult and spending time outside boosts their mental health” she adds.

When possible, Grich, in San Francisco, relies on nature’s beauty to deepen her therapeutic work. During a recent session, a patient noticed a falcon in a tree nearby. The observation served as a conversational prompt about awe and the meaning of life.

“At a time when life is unstable, knowing that nature keeps flowing — no matter what — is a powerful message,” she says.