Couch to Flourishing: A Case for Walk-and-Talk/Run-and-Talk Therapy
My first office as a therapist came with one of the uglier couches I have seen. Inherited from the clinician who occupied the office before me, the couch was rumored to have been “rescued” from a nearby dumpster and sported a faux-velvet covering the color of three-day-old pea soup. Still, I remember taking a picture that I sent to my family’s group chat with the excited caption, “My first therapy couch!” The quintessential staple of the therapist’s office since psychology’s early days, the couch felt like a hallmark of legitimacy. A few hours later, that illusion was shattered as my first client took a seat, only for one of the couch’s legs to collapse, causing the client to tumble across the floor of my office. I am not one for superstition, but if I were, I might have taken this as an omen. Regardless, it was a coincidence that a few months later, a client asked about taking sessions out of my office and onto a nearby trail. I was willing to try, and the result was noticeable; the client, who often ended sessions early and fidgeted throughout, found a pace that felt comfortable for them and opened up as I matched their stride. The experience left me wondering about what it would be like to more regularly take therapy beyond the office, and a recent move toward mainstreaming walk-and-talk, or even run-and-talk, therapy would suggest I am in good company
What is Walk-and-Talk/Run-and-Talk Therapy?
At its simplest, walk-and-talk therapy is a changing of the “therapeutic frame” between a clinician and client. Rather than sitting in the therapist’s office, the therapist and client conduct sessions while going for an outdoor walk. In this setting, the therapist and client maintain many of the traditional elements of the therapeutic relationship (i.e., empathic support, identification and examination of thoughts and emotions, development of coping skills, etc.) while also integrating physical activity and time outdoors or in nature. Qualitative research on clients’ perceptions of walk-and-talk therapy indicates that clients often enjoy and perceive benefit and comfort stemming from less formality in sessions, greater equality in the therapeutic relationship, and calmness associated with movement (Newman & Gabriel, 2022). Run-and-talk therapy seeks to reap the same benefits of framework change but at a higher intensity. In this framework, client and therapist find a “conversational” pace (i.e., one at which both the clinician and client can maintain a normal conversation without significant effort that may detract from the conversation) and conduct the session while running. For some, the stillness of traditional therapy sessions can feel overwhelming; walk-and-talk and run-and-talk sessions offer such clients the opportunity to cope through movement in an environment that may feel more approachable.
The Evidence: Behavioral Activation
When I mention walk-and-talk or run-and-talk sessions to colleagues or clients; its often met with a sentiment along the lines of, “It’s a cool idea, but that sounds like ‘a lot’ going on in a session.” The feedback makes sense; movement and a less controlled environment can feel like confounding variables that may distract from the work being done in session, but the rationale is that walking and running can actually be an integral part of “the work.” Behavioral activation” is recognized as one of CBT’s frontline interventions against depression (Beck, 2020). At its core, behavioral activation recognizes that depression, and similar mood states, often come with a drop in motivation, which decreases the likelihood that one will engage in enjoyable activities, creating a “downward spiral” (i.e., one avoids activities because they feel depressed, and they feel depressed because they are not engaging in activities that could make them feel better). In turn, behavioral activation encourages one to schedule (and monitor participation in) activities that are likely to increase feelings of pleasure and mastery, repeatedly “activating'' positive emotion states that, over time (particularly when paired with other interventions and therapeutic techniques) improve a person’s overall mood and outlook (Beck, 2020). In a traditional session, behavioral activation revolves around providing clients with tools for identifying and scheduling regular participation in activities that are likely to increase feelings of pleasure and mastery. A barrier though, is that clients may struggle to maintain motivation to engage in these behaviors outside of session. In contrast, if a therapist is able to engage in such a behavior (like walking or running) with the client, the therapist offers an opportunity for practice that may feel more approachable than attempting alone, thereby kick-starting behavioral activation so that the client is more likely to engage outside of session.
The Evidence: Exercise and Mental Health
Exercise is often an go-to option for behavioral activation, as it promotes physical health and well-being, can easily be structured/scheduled, and is a practice with a close relationship to pleasure and mastery (e.g., we experience “runner’s high” and can measure our progress by running longer and faster). Beyond behavioral activation though, the link between exercise and mental health is well established. John Ratey’s “Spark: The Revolutionary New Science of Exercise and the Brain” (2008) serves as a deep-dive on the benefits of exercise (with an emphasis on moderate-to-high intensity cardiovascular exercise) for a range of mental health concerns. Ratey writes, at length, about the mental health benefits of broad exercise initiatives in school systems as well as the way regular intense exercise changes the structure and function of the brain. Countless studies and meta-analyses have supported these claims (Oswald et al., 2020; Morres et al., 2018; Stathopoulou et al., 2008), even showing that exercise performs as well as medication as a standalone intervention while also improving the outcomes when used as an adjunct treatment (Verhoeven et al., 2023). Despite this clear connection, I sometimes find myself hesitating to recommend exercise to therapy clients, for fear of sounding demanding, reductionistic, or invalidating. “Just do it” may work for Nike, but it can come across as callous to those struggling with personal change. Anyone who has started to exercise after a period (or lifetime) of abstaining can tell you that the first few steps in a practice of running or walking can feel Herculean. That said, we know that social facilitation improves outcomes for exercise (Edwards et al., 2018); a quick look at the number of options for group or guided fitness provides evidence for this out in the real world. If a therapist is able to guide a client through their initial steps or to help them build it into a regular practice, there is an opportunity to process barriers and judgements in real time, shifting the mantra from “Just do it,” to “Let’s do this together.”
Special Considerations
Walk-and-Talk/Run-and-Talk sessions may work better for some than others. For those who shudder at the thought of traditional therapy, the alternative session structure may feel more approachable or give them a means of coping with the discomfort of therapy. At the same time, those who have a strong aversion to walking/running, are easily distracted, or have a tendency to avoid difficult emotions may struggle to attend to sessions in a less focused environment and modality. Additionally, therapies involving exercise are likely contraindicated for those with some types of disordered eating or exercise addiction, as over-exercising can be a feature of or a way of exacerbating such problems. Finally, sessions held outside of the therapy office present complications in terms of confidentiality. Obviously, clinicians should always strive to practice within the confines of the law and best practices when it comes to client privacy, but sessions held in public spaces, like sidewalks, greenways, and trails, are inherently more visible than those held in a private office. Clinicians should discuss potential risks to confidentiality with clients before their first attempt at walk-and-talk/run-and-talk sessions and agree on an appropriate plan for coping with being seen in public together.
Getting “Off the Couch”
The therapy couch will always have its place. Certain techniques and skills may be nearly impossible to develop outside of the office, and the most vulnerable topics are likely best discussed in settings where clients can feel as safe and private as possible. Regardless, there are plenty of other reasons why movement could improve the typical therapy session. Over the years, I have heard the refrain of “[insert exercise of choice] is my therapy” countless times. To be clear, exercise on its own is not therapy; it can be an important part of a mental wellness regimen, but therapy is therapy. That said, exercise and therapy do not necessarily have to be completely separate parts of that regimen. Walk-and-talk or run-and-talk therapies just might be a step (pun fully intended) in that direction.
References
Beck, J. S. (2020). Cognitive behavior therapy: Basics and beyond. Guilford Publications.
Edwards, A. M., Dutton-Challis, L., Cottrell, D., Guy, J. H., & Hettinga, F. J. (2018). Impact of active and passive social facilitation on self-paced endurance and sprint exercise: encouragement augments performance and motivation to exercise. BMJ open sport & exercise medicine, 4(1), e000368.
Morres, I. D., Hatzigeorgiadis, A., Stathi, A., Comoutos, N., Arpin‐Cribbie, C., Krommidas, C., & Theodorakis, Y. (2019). Aerobic exercise for adult patients with major depressive disorder in mental health services: A systematic review and meta‐analysis. Depression and anxiety, 36(1), 39-53.
Newman, E., & Gabriel, L. (2023). Investigating clients' experiences of walk and talk counselling. Counselling and Psychotherapy Research, 23(1), 125-133.
Oswald, F., Campbell, J., Williamson, C., Richards, J., & Kelly, P. (2020). A scoping review of the relationship between running and mental health. International journal of environmental research and public health, 17(21), 8059.
Stathopoulou, G., Powers, M. B., Berry, A. C., Smits, J. A. J., & Otto, M. W. (2006). Exercise Interventions for Mental Health: A Quantitative and Qualitative Review. Clinical Psychology: Science and Practice, 13(2), 179–193.
Ratey, J. J., & Hagerman, E. (2008). Spark: the revolutionary new science of exercise and the brain. New York, Little, Brown.
Verhoeven, J. E., Han, L. K., Lever-van Milligen, B. A., Hu, M. X., Révész, D., Hoogendoorn, A. W., ... & Penninx, B. W. (2023). Antidepressants or running therapy: Comparing effects on mental and physical health in patients with depression and anxiety disorders. Journal of Affective Disorders, 329, 19-29.
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