**Outdoor Therapy: An Interpretative Phenomenological Analysis Examining the Lived-Experience, Embodied, and Therapeutic Process through Interpersonal Process Recall**

#### **Heidi Schwenk**

School of Adventure Studies, West Highland College, University of the Highlands and Islands, Scotland PH33 6FF, UK; heidi.schwenk.whc@uhi.ac.uk

Received: 17 March 2019; Accepted: 16 July 2019; Published: 25 July 2019

**Abstract:** This research explores an innovative methodology for understanding the process and practice of UK-based outdoor therapists. Recent studies address the need to expand circles of knowledge, and capture the lived-experience of outdoor practitioners to examine the 'altered' therapeutic process and frame. Interpersonal process recall (IPR) methodology offers a nuanced and contextualised lived-experience of outdoor therapists. IPR includes three phases: (1) initial-interview; (2) post-session-reflective-recording; and (3) an IPR-interview to replay and explore the participants' recorded reflections of the outdoor therapy session. The sample included three UK-based outdoor therapists. Interpretative phenomenological analysis was used to qualitatively analyze the data. The study presents the theme of 'transitional landscapes—transitional thinking', which explores the embodied experience, the parallel process between the client and therapist, and watching for drift. The findings provide insight for training and supervision and generates constructive dialogue amongst outdoor therapists. The research supports IPR as a methodology offering participant and researcher experiential and reflective positions. Parallels are drawn in relation to existing research, literature, and contemporary professional issues surrounding outdoor therapy as a mental health treatment.

**Keywords:** outdoor therapy; phenomenology; therapeutic process; embodiment; lived-experience

#### **1. Outdoor Therapy**

The search for common meaning in outdoor therapy has proven to be challenging [1]. Discussions across the world have sought, and continue to seek, a mutual definition for outdoor therapy [2,3]. Whilst acknowledging the multiple definitions and forms of practice in the UK, this study attempts to narrow the focus to outdoor therapy, which includes a range of constructs relating to natural and wild places. This encompasses a variety of outdoor activities and therapeutic modalities to integrate a three-way relationship between the client, practitioner, and the environment. Johnson [4] (p. 72) suggests a definition of outdoor therapy in the UK based on a multidisciplinary forum held in 2006 by the University of Central Lancashire, which invited the British Association for Counselling and Psychotherapy (BACP), the United Kingdom Council for Psychotherapy (UKCP), and the Institute for Outdoor Learning (IOL). Johnson [4] (p. 72) states that outdoor therapy:

"(1) Uses a process of supported self-discovery to promote wellbeing and change.

(2) Has some experience that takes place out-of-doors (recognition of interconnection to the environment and other themes).

(3) Recognizes the outdoor place is an active component in the therapeutic process and that the process involves other components such as place, experience and reflection.

(4) Understands that reflection (not reviewing) for the therapist and client is an integral part of the process and that these reflective processes include what is happening for both the therapist/practitioner and the client and their relationship to the outdoor place."

#### *1.1. The Role of the Therapist*

Outdoor therapy brings together the intrinsic benefit received from outdoor environments with an intentional therapeutic approach. Nature-based interventions are emerging, offering health benefits and well-being outcomes, at the same time as cost effective alternative psychological therapies are being explored. "There are now numerous local and national organisations offering a range of nature-based interventions as specifically designed and structured health or social care treatment interventions" [5] (p. vi). Despite the growing demand and provision, there is limited literature surrounding the process of working with nature in therapy [6], the therapeutic frame, and practice issues [3]. The literature lacks an understanding of the role of the outdoors, looking at nature as a place to be utilized rather than central to the therapeutic process [7].

Outdoor therapy alters the therapeutic alliance (professional relationship) between the client and the therapist. In outdoor therapy, the outdoors is described as an intimate other within the counselling relationship; a third entity which provides a dyadic encounter, embodied, multi-sensory, here-and-now experience that differs to traditional therapy within a consultation room [8]. As such, outdoor therapy shifts the professional role of the therapist, allowing them to experience a new, revitalized definition of themselves with clients, which is more collaborative, dynamic, and emergent. McKinney [9] suggests the neutral and shared outdoor space and use of physical activities encourages a collaborative framework of practice. Therapists become responsive to the client's needs, promoting empowerment, equality, and client-centred practice [1]. The therapeutic space "collaboratively emerges, is constantly negotiated and is unique with each client" [1] (p. 10). McKinney [9] suggests that working in this way can speed up the pace at which the client and therapist begin to engage with presenting issues. However, there remains a lack of contextualized accounts explaining this process and its impact on intimacy and the therapeutic relationship. Whilst previous studies have contributed to understanding the altered client–therapist dynamic [3,7,9,10], there remains scope to understand the lived-experience of these encounters in greater depth and gain nuanced accounts from practitioners [6]. Similarly, Revell and McLeod [1] encourage researchers to investigate an accurate perception of both positive and negative accounts from practice to further discussion around best-practice.

An understanding of outdoor therapy approaches depends on in-depth analysis of present approaches and processes in action. The therapeutic process has multiple meanings; the process of change, the ingredients that contribute to outcomes, the abstraction and conceptualization of experience, and applied skills in context [11]. Bragg and Atkins [5] advocate that the knowledge of process is vitally important as the outdoor therapy field strives to become recognized as a viable therapeutic treatment and alternative to mainstream therapies. Understanding the process is essential for gaining funding [11], and for offering clear training, guidance, supervision, and discussion for practitioners using the outdoors [1]. Crucially, it is important to offer transparency and clarity to clients about the outdoor therapy approach [11].

#### *1.2. The Outdoor Environment: Figure or Ground?*

Within the field of outdoor therapy, the outdoor environment has a wide range of applications. There is some debate on whether outdoor therapy is a modality of its own or an integrative approach, combining theories and practices from multiple modalities [1,9], and whether outdoor therapy is used as a task, goal, or method within the therapeutic process. As an idiosyncratic field, the application of outdoor therapy seems to depend on the practitioner's personal background, training, and discipline. Berger and McLeod [12] advise therapists consider the role of nature; whether they are working in the foreground; adaptively as an active part of the process, the backdrop; space to journey within the therapeutic relationship; or using nature as a container, witness, or mediator. They suggest

it is possible to shift between these uses of the outdoors as appropriate to the client's needs [12], and understand the evolving interplay between the outdoor environment, therapist, and client. Within gestalt psychotherapy, the therapist responds to both the figure (background and context of the client) and ground (presenting issues that emerge) to focus the work whilst being mindful of the whole [13,14]. With outdoor therapies, the figure and ground take on new meaning and become experiential, metaphorical, and industrious [15]. As such, a "tripartite therapeutic partnership" is formed between the client, nature, and therapist whereby each can be affected by the others [6] (p. 66).

Outdoor therapists can help clients access an embodied experience, where sensual and cognitive epistemologies can be explored [16]. "To 'walk-and-talk' is to harness an interplay between physical movement and therapeutic conversation in the outdoors that results in an integration of space, place and embodied experiencing" [17] (p. 10). The altered physicality of working outdoors offers nonverbal synchronicity between the client and therapist [1], contributes to a greater abstract conceptualisation [18,19], increases thought processes which can loosen stuck thinking and forge new connections between different concepts [20], and can exaggerate passions, mystical experiences, and sensory appreciation [21]. From a cognitive perspective, Gibbs et al. [22] suggest embodied experiences can alter the clients use of language and allow them to articulate affective and metaphoric connections which were previously inaccessible. Physical movement can facilitate a transition from the internal stuck place as it encourages creative freedom [1]. Central to the therapeutic process are the aspects of change within the modality and the therapist's ability to use these elements in-the-moment. These aspects can range dramatically, such as adventure therapy, which emphasizes adventurous activities as the stimulus for change, compared to wilderness therapy, which favors solo time for reflection [1]. Conversely, some outdoor therapies, such as nature-based therapy, ecotherapy, and nature therapy, consider the natural environment as fundamental within the therapeutic process [1]. In most cases, the therapist's modality reflects the benefits they see in the use of landscapes [23]. Whilst a pluralistic view might consider, "clients benefit from different things at different stages in their therapy" [17], it is noted the word 'things' in the field of outdoor therapy has a broad interpretation.

Taking therapy outside can introduce an unpredictability and uncertainty within the therapeutic experience and is likely to alter the therapeutic frame [24]. Nature can be used as a container and safe place for the process to unfold [3] and can help the client find connection with their body, soul, and the land [25]. Harris [23] notes conflict between authors surrounding the importance of traditional therapeutic boundaries, as Totton [26] claims boundaries might interfere with the therapeutic relationship, compared with McKinney [9], who holds value in these structures. McMullan [27] considers nature's rules demand the therapist and client to play by a new rulebook, which cannot always be controlled. For McKinney [9], nature's control does not affect the rules transferred from traditional therapy, although it presents an ability to be casual and offer a less intimidating form of therapy. The therapist can adapt therapeutic activities in new contexts and re-configure their role, skills, and abilities. Conversely, some write of the mutual benefit of restoration and nurture in outdoor practices, allowing the therapist to remain separated from client material and avoid burnout [1].

This research investigates the therapeutic use of 'the outdoors' within outdoor therapy by exploring the process and embodiment in relation to other psychotherapeutic practices. Further, the study seeks to extend IPR methodology to gain an in-depth account of the lived-experience of UK-based outdoor therapy practitioners.

#### **2. Methods**

#### *2.1. Interpersonal Process Recall*

A process-focused interview technique, interpersonal process recall (IPR), was used to collect data. This unique methodology was applied to gain an in-depth and contextualized account of the practitioner's reflections of an outdoor therapy session. IPR allows the inquirer (researcher) and recaller (participant) to come to a common understanding about the recaller's experience [28]. Created for corporate use, Kagan [29] developed IPR to understand professional responses for training purposes. Inskipp [30] later introduced IPR for counselling training, which has led to its application in reflective practice and studying therapeutic interactions [31]. Although IPR has been reported as an effective means of investigating therapeutic processes, there is limited research applying its methodology [32]. Brown et al. [33] advocate IPR as a person-centered design that increases the participant's reflection and involvement. Kettley et al.'s [28] account of IPR offers a rationale for its philosophical congruence with phenomenological and person-centered approaches, with a particular emphasis on enabling participant-led research.

IPR captures a qualitative-rich, in-the-moment, and specific account of interactions and processes [34]. McLeod [35] (p. ix) relates qualitative research to psychotherapy, which gains "holistic, nuanced, personal, contextualised, incomplete" data. IPR assumes that within the moment, multiple thoughts, feelings, and sensations are experienced but not necessarily recognized [36]. Whilst Macaskie et al. [37] note IPR recalls individual's conscious but often unprocessed thoughts, Finlay [38] (p. 10) recognizes "sometimes it languages things we already know tacitly but have not articulated in depth. At other times, quite surprising insights reveal themselves." A recent study found IPR allowed the researcher and participant to actively share the meaning-making process and co-construct research conversations [37]. The process-focused interview extracts insights through observation and direct questioning as the recollections unfold, paying close attention to context [34]. Kettley et al. [28] note the parallels between phenomenological studies which seek transparency and person-centered practices, which advocate congruence. IPR could offer new ground to explore a practitioner account that is embodied, nuanced, and contextualized and a method which engages the participant to become actively curious and reflective of their personal practice.

#### *2.2. Sample*

Phenomenological studies use small homogenous samples to examine convergence and divergence [39]. Purposive sampling allowed for three participants to be selected for their suitability [40]. All participants were registered or accredited counsellors of a Professional Standards Authority with between 7 and 20 years of experience as practitioners:

Participant A: Works with individuals indoors and outdoors with a person-centered modality and uses various outdoor sites from local parks to mountainous regions (male).

Participant B: Works with individuals indoors and outdoors following a person-centered modality within a pluralistic agency, using woodlands, parks, and fells (male).

Participant C: Works with groups and individuals in indoor and outdoor venues, using an integrative approach combining Gestalt, Jungian, transactional analysis, and person-centered theory and aspects of coaching and wilderness therapy (male).

#### *2.3. Informed Consent*

Participants received information regarding the process, aims, contribution to research, and right to withdraw [41]. Within a very small industry of outdoor therapists within the UK, participants were warned that despite the appropriate use of pseudonyms and the removal of sensitive and place-specific data, they may be recognizable through their narrative.

Bond [42] warns researchers in counselling and psychotherapy that client confidentiality could be compromised with in-depth data. As a result, the research participants were briefed to maintain client anonymity and given the opportunity to read and censor sensitive data from the transcripts as encouraged by Henry and Fetters [43]. "Honouring any promises about confidentiality carries special ethical weight because this is central to practitioner and researcher trustworthiness in this field of work" [42] (p. 7).

#### *2.4. Procedure*

To respect client confidentiality and avoid interference to the client's therapy, this research focused on the therapist. Data collection involved a three-step procedure:

Step 1: A face-to-face initial-interview: To gain background and contextual data on the participant's practice and philosophy of outdoor therapy. Digitally recorded and transcribed (45 to 60 min).

Step 2: Post-session-reflective-recording: Using a semi-structured list of reflective questions, participants remotely recorded their immediate reflections after an outdoor therapy session to gain an uninhibited account of the participant's lived-experience. Recorded (participant's smart-phones) and transcribed (30-minutes).

Step 3: Face-face IPR-Interview: The participant and researcher listened to the post-sessionreflective-recording together at the participant's working location. The researcher and participant were able to pause the recording at points of interest to gain depth, perspective, and insight (60 to 90 min).

In IPR, "Interviewees are cued to remember various reactions and ideas that occurred during the session but might not readily come to mind unassisted" [34] (p. 1). "The IPR process slows down the interview conversation, giving interviewees time to meditate on and verbalize complex experiences" [34] (p. 3). Similar to Brown et al.'s [33] study, the post-session-reflective-recording was used as a stimulus for reflection, to replay and invite participants to pause and recall thoughts and feelings not commented upon within the original recording. This allowed for a deeper understanding of the subjective experience, a point of reference to gain perspective upon, and gave voice to participants to re-encounter their account. This multi-layered approach offers a unique methodology of examining the phenomenon.

#### *2.5. Ethical Considerations*

Ethical approval was granted by the University of Worcester [44] and reflects the British Association for Counselling and Psychotherapy's research ethical guidelines [45] and the Economic and Social Research Council's [46] ethical guidance framework.

#### *2.6. Researcher Bias*

Whilst psychology is concerned with the unavoidable presence and meaning systems inherent to the researcher, IPA embraces the relationship between researcher and subject matter [39]. The researcher's personal bias stems from involvement as an outdoor educator, integrative counsellor, and individual using the outdoors restoratively.

#### *2.7. Analysis*

Interpretative phenomenological analysis (IPA) offers a qualitative approach to investigate participants' experiences, examining how people make sense and understand the experience in its own terms [47]. As such, IPA is often used alongside interviews to "recall the parts and their connections and discover this common meaning" [39]. This experiential approach invites the researcher to engage creatively with the participants' reflections [39]. Considering the interdisciplinary theories related to outdoor therapy, the ideographic nature of IPA is called upon to understand "what the experience for this person is like, what sense this particular person is making of what is happening to them" [39] (p. 3). This appears appropriate for outdoor therapy as "services in this field (are) using different language to describe their activity and benefits, operating different delivery models and using different measurements of impact" [5] (p. vi). Whilst this research favors a qualitative in-depth methodology to explore outdoor therapy practice, Smith et al. [39] warn exploratory and interpretative research findings should not be regarded as exhaustive but can generate new areas for inquiry. IPA involves iterative analysis, moving back and forth at different ways of looking at data, rather than sequentially [48]. A major principle of phenomenology is to move past taken for granted assumptions and discover the essence of experience [49,50]. Like many strands of humanistic counselling, phenomenology regards

participants as the expert of their experience and warns researchers not to re-word or label extracts [49]. Allen-Collinson [49] advises researchers to include original extracts to speak for themselves, record researcher conceptualizations, and use triangulation to validate findings. This research follows Smith et al.'s [39] (p. 84) guidelines, dissecting the transcript using:

"Descriptive comments focused on describing the content of what the participant has said, the subject of the talk within the transcript ... Linguistic comments focused upon exploring the specific use of language by the participant ... Conceptual comments focused on engaging at a more interrogative and conceptual level".

From these descriptive, linguistic, and conceptual comments, emergent themes were generated before examining the cases and searching for connections across themes and abstracting patterns across cases to form super-ordinate themes [39,51]. Owing to the multi-layered analysis, the research was manually coded as the researcher's preferred coding method. The researcher had previous experience of IPA as a post-graduate student. This process involved reading, re-reading, familiarization, immersion, and incubation through continued engagement with the recordings and transcripts [52]. The researcher made notes of codes and then themes through abstraction; putting like with like, subsumption; identifying a theme which acts as a magnet to other themes, and polarisation; focusing on the difference between themes rather than similarities [39]. Whilst this process provided opportunity to engage with data in different forms, Smith et al. [39] recognize the researcher often moves into deeper stages of interpretation, whereby they begin to understand the data. The super-ordinate themes arrived at offer a compromise between a systematic and intuitive analysis process, which reflects not only the participants' lived-experience but also the researcher's interpretation [39,53].

#### **3. Results**

The original research submitted to the University of Worcester included five themes. This paper presents one theme: 'Transitional landscapes—transitional thinking'. This theme was chosen as it best demonstrates the application of interpersonal process recall in gaining an in-depth and nuanced understanding of the environment within the session. The theme is broken into subthemes including; the embodied experience, parallel processing, and watching for drift.

#### *3.1. Transitional Landscapes; Transitional Thinking*

Outdoor therapy can be direct (working outdoors from the start), planned (starting indoors with a plan to move outside), combined (using indoor and outdoor spaces on alternate or particular sessions), or emergent (finding opportunity for the work to progress to an outside space). Emergent opportunities arise where the client learns and becomes interested in an outdoor approach or where the practitioner gets a sense that working outside might be safe and beneficial to the client. As with traditional counselling, the initial sessions are important for establishing the therapeutic relationship, ensuring there are clear and contracted boundaries of practice and establishing the focus of the work and whether the practitioner's modality will suit the client.

Compared to indoor counselling that is often assisted with a clear transition from the waiting room to the contained counselling room, in a direct approach, where the client and practitioner meet and start working outside from the beginning, there is a less clearly defined transition. Participant C describes one approach using the environment and assisting the client to make a transition between landscapes and beginning the therapy session.

"We'd get to the bridge at the head of the lake ... that's like a passage and I'd say to people ... when we come off the tarmac road I'd invite them to think about their leaving one kind of environment and going into somewhere else". (Participant C)

This approach uses a land feature to symbolize the transition into the therapeutic session. It indicates that for participant C, the session offers an escape from everyday life and a passage into an

alternative space. The journey becomes metaphoric as well as physical as the participant transitions from one space to another. Conversely, participant B describes a combined approach whereby the outdoors is used as an experiential space to explore the therapeutic work.

"He chose a route through some paths, woodland paths and ended up going off track and over walls ... it was almost quite playful, and quite a sense of lostness and re-emerging and all that kind of stuff he was experiencing which mirrored some of our indoor sessions, literally as opposed to metaphorically". (Participant B)

In this example, the client is able to actively experience some of the metaphoric content of an indoor session, the metaphors of being lost and finding themselves are given a literal meaning as the client navigates through the forest. A combined approach allows for the client and practitioner to work with the presenting issue through rational, reflective and abstract forms.

As the sessions progress, the client may become more confident to work with the practitioner and the outdoor approach. The sessions transition from beginnings (getting comfortable with the approach) to middles (utilizing the approach to explore the presenting issue). Participant B describes a client's integration of the natural environment within the session. The client starts to experience an embodied agency within the outdoor environment.

"He was moving along, like in the same way that his emotions were moving ... feeling very lost, very confused ... what mirrored that process was walking along in the light, a light airy space for a little bit and then going through the woods as per his direction, and getting very lost and weaving our way through these little paths". (Participant B)

Here, the therapeutic process emerges with, and is guided by the natural environment; as the client and practitioner talk, the client is able to move into spaces of shade or light, clear pathways, or trickier terrain. The terrain affects the conversation as the natural environment stimulates the therapeutic process, providing dynamic material within the session. Equally, the client can affect the terrain by changing the path they choose; thus, enabling an embodied expression to emerge. The practitioner observes the client shifting between affecting and being affected by the environment. The practitioner's role shifts, allowing room for the natural world to interact within the therapeutic relationship.

"Just at the point where we were more tangled was when we could actually start to see the sky through the trees again ... and then saw the hope, the light through the trees and that seemed to help facilitate him getting back to himself, answering his question about the here-and-now". (Participant B)

Whilst the client can dictate the path, they are also in a dynamic and emergent terrain. After leading the way into a thick mass of trees, the environment offers a natural window and sense of perspective. The light through the trees offered a symbol of hope and provided light to the situation that shifts the client's thinking process. This is experienced physically, emotionally, and cognitively as the client finds patches of clarity within an enclosed forest. The client is able to discern the figure from the ground and return to the present moment.

"That for me is like the holy grail, when the experience of the session and the experiencing of it feels as real as what's going on internally, we hit those moments throughout that journey because the client is picking the route in tune with the content of their session". (Participant B)

The practitioner's likening of an embodied session (synchronicity between mind and body) to the holy grail indicates a sense of actualization, flow, or epiphany that is deep and powerful. To the practitioner, the client's ability to work in this way and encounter such a state of mind indicated that the session was meaningful. The practitioner's role is to dynamically facilitate this engagement with the natural environment and work with the client to offer awareness.

Being with the client outside allows other-than-spoken processes to emerge. Participant A explains that silently walking with the client was equally as useful. The session takes a different pace and allows the process of walking to hold the space between conversations.

"I think walking gave us an opportunity to share times of stillness and silence which were sometimes necessary for my client to be able to process what was going on and to find the words to say what he wanted to say". (Participant A)

Transitions in outdoor therapy take many forms. These transitions include the intentional shift from an indoor to outdoor space, the client's attunement and integration of the approach, and the shift of the practitioner to provide space for the natural environment to interact and be an active component of the work.

#### *3.2. The Embodied Process*

Outdoor therapy reframes the therapeutic relationship and offers both the client and therapist a different experience of one another. This reframe symbolically alters the perception of the role and context of the professional. The therapeutic work becomes defined, negotiated, and maintained within the context of the outdoor environment. The therapeutic process takes on additional dimensions as the client and therapist move through and engage with the environment. Participants noticed that working outdoors impacted their experience of the client:

"You feel kind of more what they're feeling and their kind of anger can become perhaps more understandable or certainly experienced anyway!". (Participant A)

Outdoor therapy offers a holistic approach. Whilst indoor counselling works mainly with the cognitive and emotional, outdoor therapy involves an active element that invites clients to be present with their emotions, thoughts, and actions. The immersive experience can impact the practitioner's ability to experience the client authentically.

"In a therapy room ... they can see the clock ... but in nature when they've been walking around in the woods and they don't really know where they are, old worries and anxieties and things may well resurface but they may be reflecting the real person rather than the person they try to be". (Participant C)

Participant C explains that outdoor therapy allows clients to become immersed in the moment, and in doing so, they might forget about how they are trying to portray themselves and start being authentic. Participant C suggests this process may lead to worries and anxieties resurfacing, which offer a more genuine experience of the client. Working with the client in an experiential way enables the therapist to observe and experience the client's way of being in real situations rather than through the client's self-reflection. This allows the therapist to engage with the client's authentic self and provides an opportunity to experiment with coping-mechanisms.

"If they don't look after themselves physically in that environment, then what does that say about them emotionally? Are they able to take care themselves?". (Participant C)

Outdoor therapy alters what it is to engage in therapy and for participant A, reframes the purpose of therapeutic encounters from clinical to organic.

"Stillness's and silences can seem a very natural part of the process of walking, whereas in a counselling room, sometimes those dark silences can seem very, yeah unbearable almost". (Participant A)

In this example, the participant reflects upon the meaning implied by stillness and silence. He suggests the tone of silence is altered when walking to resemble a natural pause, whereas within a counselling room, the tone can feel imposing and stifled. Equally, participant A reports an ability to experience their client's disconnect, their discomfort and vulnerability, and the impact of this on their work.

"One particular client ... it was very obvious there was not psychological contact between him and his surroundings ... within about ten-fifteen minutes I had this most enormous headache ... it was really frustrating because I was really feeling that sense of complete disconnection with where I was ... I was in his world, I'd kind of lost a sense of me as a counsellor ... I was as disembodied as he was". (Participant A)

Participant A details a disconnect between the client and their surroundings, which in turn affects the practitioner's ability to connect with their environment. This disembodiment affects the practitioner's sense of self. Whilst the practitioner uses the natural environment to remain grounded and focused on the client, here, the practitioner is unable to make psychological contact between nature–practitioner–client.

When removed from the traditional context of counselling and engaging experientially in outdoor therapy, the practitioner must be cautious to remain focused, rational, and professional and avoid getting lost in the experience:

"The risk is you have a genuine relationship with somebody ... then you actually feel their pain and their sorrow and their sadness". (Participant A)

Participant A considers the risk of intimacy on professionalism. He suggests practitioners working outdoors might have an altered perception of the role of intimacy in the therapeutic relationship and be more inclined to experience their clients authentically. This suggests that for participant A, the risk of intimacy is not that professional boundaries will be compromised, but that the practitioner may begin to feel their client's emotions.

"I think that's one of the reasons why counsellors are very reluctant to work outdoors because ... strangely ... it seems paradoxical because what you want is intimacy, I think often counsellors are actually very scared of true intimacy". (Participant A)

Participant A identifies a paradox whereby on the one hand the work between the client and practitioner fosters intimacy within the working relationship and on the other, professional boundaries imply that true intimacy is to be un-boundried or step over the professional boundary of practice. For participant A, professional boundaries do not restrict intimacy, nor does intimacy restrict professionalism. There is an indication that counsellors may be restricting their work through limiting the intimacy within the working relationship and that by situating work too squarely within professional boundaries, the innate human connection is lost. Despite this, participant A acknowledges that intimacy must be managed with care.

"I think trusting relationships can develop very quickly, that can also be a problem too in the sense that sometimes people might be working quicker than they actually feel comfortable with". (Participant A)

Here, the participant explains that intimacy takes time to develop between the client and practitioner. The pace, intimacy, and depth of the work are managed in the altered context. The practitioner must consider the duty of care to the client and decide what is appropriate and best for the client within the scope of the approach.

#### *3.3. Parallel Processing*

The outdoor environment provides a dynamic element affecting both the client and practitioner. The participants expressed a motivation and passion for outdoor environments as a place of self-care. These places become a working environment offering a symbiotic relationship and providing restorative conditions for both the therapist and client and a sense of rejuvenation to the therapeutic work:

"I notice that when I'm outside I can be more immediate with what is going on in the moment, I can be more focused, perhaps more available for the client ... that has an impact in terms of holding from a person-centered point of view ... holding of the necessary and sufficient conditions". (Participant A)

Participant A describes a sense of attunement to the client within the natural environment. The participant describes a sense of seeing more within the moment and being grounded in the present here-and-now in which the client is the center of attention. Here, the person-centered core conditions (empathy, congruence, and unconditional positive regard) flow naturally between nature–practitioner and practitioner–client to provide the conditions for therapeutic change. Not only is the client held, nurtured, and contained, but the practitioner too. However, the therapist must be aware of their own processes and motives within the session, putting aside their 'stuff' to be present with the client.

"My feeling is joy, I'm finally in a new place, there's a new lostness; I love exploring so for me there's an adventurous side, I love that feeling. But I love it so much that I've had to learn how to not let that get in the way of how the client is feeling ... this has taken a long time ... to both feel that excitement that I'm having in the moment ... but to be with the client and how they're experiencing that moment". (Participant B)

Participant B describes his emotional response to the sense of lostness within the session. He acknowledges his inner-reaction and sense of adventure which is parked to remain present and attuned to the client's experience. Participant B indicates a journey of realization and training that he has taken to remain present with the client and to sustain focus during the session.

Equally, the process of joining with the client and remaining responsive to the terrain and safety elements requires the therapist to dynamically examine their anxieties and intrinsic response to the land in relation to the context of the work and their code of practice;

"I keep feeling naughty about that ... like little school boys playing ... we were in this deep process literally a moment ago, but it got really steep and really windy, I had this feeling like 'we shouldn't be here' ... and I just have to let it go because I'm looking at the client just carrying on talking but he's weaving through". (Participant B)

Participant B's use of the words 'naughty' and 'school boys' indicates a more playful dynamic between the client and practitioner. The participant uses 'we', suggesting that the moment was a shared experience and state of being. The practitioner notes the change in the terrain and its impact on their movement. Here, the practitioner takes a moment to check-in and acknowledge his sense of discomfort with the situation before considering its impact on the client's safety and process. The practitioner is able to focus on the client and reserves his doubts to allow the client's process to continue. As a person-centered counsellor attuned to following the client, participant B explains the practitioner must recognize and hold their own agentic response to nature. Dissonance can emerge between the client's and the practitioner's experience.

"For me it was divine, it was heavenly, but for my client it who was feeling very suicidal at the time, he just had this deep feeling of foreboding because it was just too much". (Participant A)

Participant B offers another example, whereby their passion and motivation for the outdoors was not reflected by the client. In this case, the practitioner was forced to consider the intention behind the approach and who was benefiting from the approach.

"I was expecting them to have the same relationship to nature as I did. Which was enthusiastic, love, joy, it was amazing the best thing in the world and the first person I took outside hated it ... I was really disappointed". (Participant B)

Participant B reflects upon how he has attempted to narrow the gap between his personal experience and the client's experience using a process of intentional disorientation, within a safe and confined boundary, to become more equal, avoid complacency, and better understand the here-and-now experience.

"I didn't realize until I did this on reflecting on this ... I'm aiming for this ideal kind of equality with the client and the session ... to mirror what I'm actually doing indoors ... I wanted to actually go somewhere I hadn't been before, so that it did feel more like it does in a normal session which is new territory, new ground". (Participant B)

Taking therapy outside requires the practitioner to be comfortable and aware of their own relationship with outdoor and natural spaces. Their competence and comfort in these environments allow them to be present with their client's experience. Staying in tune with their own response, the practitioners internally supervise the session, considering the client's wellbeing and the therapeutic work aside the landscape and terrain.

#### *3.4. Watching for Drift*

Working with the client's response to nature requires and invites the therapist to experience additional roles and blurs the boundaries of the traditional therapeutic hour. This offers multiple elements for the practitioner to balance and manage simultaneously. Participant A describes the importance of finding safe conditions for the session to emerge. Where the conditions are not suitable, the practitioner adapts accordingly until conditions are met.

"Walking to the park, we would have general sort of chit-chat but we wouldn't be doing sort of deep work because I'd end up walking into a car". (Participant A)

Once safe conditions are found, the practitioner can settle into the session. Whilst the practitioner continues to dynamically assess safety, participant B describes an experience of becoming immersed in the session with the client, presenting a risk of drift from the presenting issue to the experience itself.

"I'm almost giggling here actually because I remember ... there was a part where the alliance was as if we were being a bit naughty like here we are doing a counselling session, talking about all these things and then we find ourselves weaving up, weaving up quite a steep track, not even a track, a steep wall with no track". (Participant B)

This can alter the therapeutic alliance, whereby the client and practitioner experience each other differently.

"That pretense goes, you just lose yourself ... we shared in those moments so that our eye contact was more and we were having fun". (Participant B)

The therapist shifts focus with the terrain of the session. Whilst managing safety, the therapeutic work, the client's experience, and the environment, the outdoor therapist must also follow their navigational location. Participant B describes a moment where he did not know their exact location and considers the impact of this on the client.

"I didn't know that was the way out, he did actually find it ... he thought I was pretending ... that I did really know where I was ... and I didn't. And that was really levelling". (Participant B)

This can alter, shake or destabilize the client's view of the therapist and the perceived competence, safety, and professionalism bestowed upon the practitioner.

Watching for drift requires the practitioner to juggle the different hats that they must wear to work as competent lone-practitioners. Whilst working in line with their ethical framework and seeking supervision to review their work, practitioners must be mindful of the heightened duty of care they have for clients whilst outdoors.

#### **4. Discussion**

This study adopted an interpretative phenomenological analysis to explore the participants' lived-experiences of outdoor therapy sessions. The theme presented reflects upon the use of an environment which is intrinsically therapeutic and which can lead to transitional thinking [54], and the multiphasic nature in which cognitive and psychological states ebb and flow throughout the encounter [55]. This research supports links between internal and external landscapes [56], symbolism between nature and the therapeutic alliance [12], the other-than-human-world and the reflective process within the session [25,26], and the impact of sharing external landscapes upon the therapeutic relationship [26]. There is also support that the mechanism of change depends on the therapeutic modality of the therapist [23].

This research builds upon Revell and McLeod's [1] account that the altered physicality and embodied relating between the client–practitioner/client–nature/mind–body can create opportunities for synchronicity, metaphors, and transitional experiences to emerge. There becomes a balance, whereby the practitioner must step back to let the client lead whilst containing the safety, focus, and depth of the session. The practitioner holds the process, noticing the client's physical and verbal expression, transition between states, and interaction with surroundings. Further, the practitioner notes whether the client is affecting or affected by the environment and helps to explore the links between the internal and external, delicately managing the figure and ground. The figure and ground present "ambivalent and nuanced spaces [with] many shades of meanings ... perceived as healthy and unhealthy at the same time" [57] (p. 261). The natural world provides texture, context, and stimuli to explore the figure and ground through physical, cognitive, and emotional modes.

In a process of multi-sensory involvement, the therapist becomes part of the experience, moving between witness and companion within the client's process. The therapist watches for drift from the presenting issue, aware of experiences which might become un-boundried or destabilize the process. As Baer and Gesler [58] advocate, the therapeutic potential of environments changes over time and therapists must assess the validity of the landscape on the healing process. This was confirmed as participants explained the selection, evolution, and therapeutic use of sites.

This theme builds upon previous literature, which identified the positive effect on therapists' personal psyche and ability to prevent burnout [1]. The altered therapeutic relationship is examined in relation to the impact of experiencing the client; Revell and McLeod [1] identify a process of bodily empathy, whereby therapists experience their clients more holistically. Whilst Revell and McLeod [1] note a freer and less inhibited relationship that emerges, altering the dynamic as the client and therapist move from face-to-face to side-by-side, the findings suggest the therapist is not completely uninhibited and care-free and works alongside a complex process of providing an appropriate therapeutic relationship, maintaining flexible boundaries, and being able to separate and hold their own 'stuff' apart from the client.

Like Jordan and Marshal [24], the study found the neutral space allows the therapist to be more real within a natural setting and provides deepened intimacy, although they caution that intimacy must be handled carefully. This offers an opportunity to experience the client in real time and witness the client's disconnect, discomfort, and vulnerability. This can widen the gap between the client and therapist's experience, allowing the therapist to work with the client through the issue or alter the therapeutic experience as necessary. Jordan and Marshall [24] note the ability for the experience to provide immediacy for both the client and therapist. The findings support an altered therapeutic

alliance and therapeutic role in terms of bringing more of themselves into the relationship and loosening their professional role [1]. Berger and McLeod [12] (pp. 87–88) identify the role of the therapist as "witness, container, and mediator" shifting in relation to the client's engagement with nature. In this case, it appears the therapist can also become a 'partner' with the client, experiencing together. In many cases, participants detail processes which are adapted from indoor counselling. This appears to align with McMullan's [27] considerations that the alliance is removed from traditional rules of therapy, instead locating and obliging nature's rules. However, as Harris [23] warns, participants equally detail the ability for the alliance to become destabilized based on the client's expectations of the therapist not being met or due to lacking boundaries.

#### *4.1. Limitations and Reflexivity*

The sample inclusion and exclusion parameters had specific demands of the research participants. Whilst these were upheld, an unexpected element was the scope of participants' work and range of sessions, which presented within the post-session-reflective-recordings. Such diversity is echoed in Harris's [23] research, which underestimated the range and complexity of cases presented. The diversity of cases proved difficult to hold amongst one another. For example, holding group work amongst one-to-one therapy or overnight sessions amongst 50-minute sessions. An implication for future IPR research is to specify both participant and post-session-reflective-recording parameters.

In accordance with a phenomenological approach, this research explored the thing itself, applying IPR research methodology providing a reflective stance for the participant and researcher and generating practitioner knowledge. Each stage in the IPR procedure allowed a different layer of depth to be explored and highlighted different aspects of the lived-experience. Whilst it might be argued that the findings lack generalizability, this research questions the extent to which generalized findings would benefit the field of outdoor therapy and considers it critical to know more about specific practices.

#### *4.2. Implications*

An alternative view of the therapeutic alliance was encountered whereby the practitioner and client become partners and can reveal their authentic selves. The therapist is both a participant in the experience and holds responsibility for the therapeutic encounter. The relational dynamic appears complex and needs to be considered from the client's perspective.

In addition to the many positive accounts of outdoor therapy, investigation needs to explore the experiences which drift from the therapeutic aim, distract from the goal, or destabilize the therapeutic process and the implications of such occurrences. In view of physical and emotional risk, and the reporting culture of the counselling and outdoor industries, further research might investigate the provision of support extended to lone-practitioners.

#### **5. Conclusions**

This research offers insight into outdoor therapists' lived-experience and practitioner knowledge within a specific outdoor therapy session. At the outset, the research intended to understand both the embodied experience and therapeutic process. What emerged was a detailed account of the synchronicity between the two as the therapist receives and seeks input from the natural surroundings. The findings progress from the therapist's philosophical stance, motivation, and theoretical position to a contextualized and practical understanding of the process. The data reveals the therapist's choice of therapeutic sites, impact of physicality on the dialogue, and use of the outdoor context. The IPR-interview distinguishes the therapist's perceptions for their clients and their own lived-experience and how these states are altered in transitional landscapes. These findings highlight the significance of an altered therapeutic partnership and the impact of parallel experiencing upon the therapeutic encounter. These factors were considered in relation to the therapeutic frame and the practicalities and difference of working outdoors.

Whilst acknowledging limitations presented by a diverse sample, IPR offers a tool for future research, enabling both the participant and researcher an experiential and reflective stance. Further research is needed on the client's lived-experience, and an understanding of the process and embodied-experience. An understanding of positive and negative experiences could inform practice, and offer insights for appropriate training and supervision, and generate constructive dialogue amongst outdoor therapists.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


© 2019 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

## *Article* **GOING GREEN: The E**ff**ectiveness of a 40-Day Green Exercise Intervention for Insu**ffi**ciently Active Adults**

#### **Nicholas Glover \* and Scott Polley**

Alliance for Research in Exercise, Nutrition and Activity (ARENA), School of Health Sciences, University of South Australia, Adelaide 5001, Australia; scott.polley@unisa.edu.au

**\*** Correspondence: nicholas.glover@unisa.edu.au; Tel.: +61-421-612-340

Received: 19 May 2019; Accepted: 7 June 2019; Published: 13 June 2019

**Abstract:** Increasing physical activity and reducing sedentary behavior is an economic and health priority. This Green Exercise (GEx) study reports on a 40-day physical activity intervention to increase physical activity that primarily used outdoor recreation activities. Adherence, compliance, blood pressure (BP), total cholesterol, anthropometry, strength, dynamic stability, and cardiovascular fitness were assessed 1 week prior and immediately following the 40-day intervention. The results then were compared with a larger study that used the same methodologies but for the exception of primarily indoor physical activities. Results from this study showed similar improvements in health measures to the comparative indoor-based physical activity program with increased adherence and compliance. Improvements in wellbeing were also noted. This GEx study suggests that exercise programs that seek to increase physical activity levels of insufficiently active adults may benefit from including outdoor recreation activities within the program and may also increase participant mental health and general well-being.

**Keywords:** green exercise; adherence; compliance; health; outdoor and adventure activities

#### **1. Introduction**

Western societies are much less physically active than our pre-industrial forebears and far less active than the humans who were our ancient ancestors [1]. Technological advances have resulted in changes to the way we live following the onset of the agricultural and industrial revolutions and the digital age [2]. These changes now mean that we are less likely to be engaging in physically active behaviors as we spend more time in built environments and less time in agrarian or natural environments.

Physical Inactivity is thought to be the fourth leading risk factor for global mortality (following high blood pressure, smoking and diabetes) and is the main cause of 21–25% of breast and colon cancers, 27% of diabetes and 30% of ischemic heart disease [3]. Physical inactivity, along with unhealthy diet, tobacco use, and excess alcohol consumption is a key contributor to 28 million deaths from non-communicable diseases [3]. Increasing physical activity (PA), eating well and reducing smoking is thought to have the potential to prevent 80% of premature heart disease, 80% of type 2 diabetes and 40% of cancers [3]. Physical activity is also known to positively affect mental health [4] with depression now the leading cause of disability world-wide, affecting an estimated 350 million people [5]. Despite positive benefits of PA, estimates from Australian state and territory surveys suggest that less than 50% adults are achieving sufficient levels for health [6].

Addressing sedentary behavior is now a global health challenge [7]. Direct PA interventions have been shown to positively affect behavioral change in terms of participants' adherence and compliance to exercise following a program [8,9]. Recent systematic reviews provide some direction for PA interventions to be more successful in promoting adherence (the extent to which participants continue in a program to its conclusion) and compliance (generally defined as the extent to which participants

meet a prescription of PA) [8–10]. Intervention strategies that engage participants in PA behaviors were more likely to be effective than cognitive variants [11]. Group-based and educational interventions were found to be more effective in the short-term when compared to home-based strategies [12]. Long-term interventions were found to be more effective for older (compared to middle-aged) populations and when using booster strategies such as providing educational materials [9]. The use of monitoring devices [13] shows promise for increasing adherence and compliance for those with identified conditions [13,14].

Barton and Pretty [15] theorized that PA in outdoor and natural environments provides increased benefits compared with exercise in indoor environments. A recent term, 'Green Exercise' (GEx) was coined and defined somewhat broadly as exercise in the presence of nature [15]. Supporting this theory, a small number of studies comparing PA in 'non-green' and 'green' spaces suggest that natural views and natural environments may increase PA participation [16], intensity levels [17,18], physical health [10,18–27], and mental health benefits [10,17,18,25–35].

No studies were found prior to this intervention that assessed comparative adherence or compliance rates as part of intervention programs for insufficiently active adults; therefore, any beneficial effect GEx might have on increasing levels of PA has not previously been tested in this population.

Withdrawal from PA interventions and general exercise programs is a recognized problem [36–39]. It is theorized that adherence is affected in part by the environment in which people exercise [10,33] and that GEx might positively influence adherence [30,40–42]. Nearly half of indoor sports participants drop out within the initial 6 months, whereas it has been reported that walking outdoors is a preferred form of exercise to maintain adherence [43].

Theories about possible increases in exercise adherence and compliance with GEx include attention distraction [30], costs associated with exercise [33] and the biophilia hypothesis proposed by Kellert and Wilson [44] suggesting humans have an innate attraction to nature. Mackay and Neill [32] theorized that the greater the 'greenness' of an environment, the greater the potential benefit to those immersed in it.

To investigate the comparative role of GEx with other exercise interventions in promoting adherence and compliance, a previously successful larger scale 40-day PA intervention by Norton et al. [45] that primarily used indoor environments [45] was replicated in structure, with the exception of the group activities that replaced indoor-based with outdoor-based pursuits. Norton and colleagues' [45] study incorporated three intervention arms: (1) a pedometer-based group with no direct facilitation (*n* = 251); (2) an active control group consisting of sufficiently active subjects continuing to meet recommended weekly requirements for PA (>150 min/week; *n* = 135); and (3) an instructor-led cohort utilizing group-based and individual exercise sessions, largely indoors (*n* = 148). Results from Norton and colleagues' [45] study indicated that this latter intervention arm was most successful at improving PA participation and associated health measures, and therefore, was modelled for this study, but with a GEx focus.

The primary aims of this study were to measure program adherence and exercise compliance among participants undertaking a 40-day daily PA intervention based on GEx. Secondary aims included to determine the changes in a range of physical, physiological and psychological variables following the intervention and to compare the changes in the GEx intervention with those previously reported by Norton et al. [45]

#### **2. Materials and Methods**

Recruitment for the 40-day GEx Intervention occurred through numerous mechanisms: Firstly, via email throughout the University of South Australia and a number of South Australian government departments; secondly, through a news story in a local newspaper; and thirdly, via recruitment posters placed around the University City East campus.

Inclusion criteria for both studies was insufficiently active (<150 min/week of moderate-to-vigorous PA assessed using the Active Australia Survey [46]); otherwise healthy; 18–60 years of age; available for a 40-day PA program. The structure included three instructor-led group sessions per week, being 19 group sessions in total over the 40 days. Group sessions ran for a minimum of 30 min and were planned to progressively increase participants' energy expenditure (EE) requirement each session. On non-group days, participants were asked to undertake their own exercise session for a minimum of 30 min, totaling 21 of the 40 sessions. The program ran throughout April, being autumn in the southern hemisphere. Norton's [45] study had 11 indoor sessions undertaking training activities that included circuit training with weights, stair climbing, stretching and resistance activities, aerobics, and spin-cycling classes. Six activities took place at nearby city parks (jogging, soccer, stretching), with two group sessions planned to take place in more natural environments. The program ran during autumn, winter and spring. By comparison, this program of GEx (Table 1) included only outdoor recreation activities in local, easily accessible green spaces, using the criteria outlined by Mackay and Neill [32].

The settings included places such as parklands, riverside settings, conservation parks, and marine and coastal environments (Figure 1). Activities included walking, low organization team games, challenge activities, yoga, kayaking, cycling, rock-climbing, and orienteering all conducted in an outdoor environment. The program itinerary used freely available and conveniently located (near-city) public green spaces with the intention to introduce participants to a diverse range of recreational activities that could be undertaken beyond the program (Table 1).

Participants attended the group sessions three times per week (Tuesdays, Thursdays and Sundays) for activities conducted by trained instructors and undertook an activity of their own choice on alternate days (Table 3). The activity sessions were designed to expend approximately 800 kJ in the first week increasing by approximately 200 kJ in each subsequent week. All sessions included a 10-min warm-up and cool-down with a stretching period. Weekday sessions lasted 60 min and Sunday sessions around 90 min. Where possible, the core of the session had subjects working between 60–80% of age-predicted HRmax (220-age in years). This was not always attainable due to the nature of the activities, for example rock climbing which requires bouts of intense activity interspersed by rest.


**1.**Itineraryforthe40-dayGExProgramCommencing30April.

 Target daily energy expenditure.

\*

(**c**) (**d**)

**Figure 1.** Samples of group exercise sessions and locations around Adelaide, SA. (**a**) Walking along River Torrens Linear Park; (**b**) orienteering in Belair National Park; (**c**) team games at Victoria Park; (**d**) kayaking at the Adelaide Dolphin Sanctuary, Port River; (**e**) walking the Marion Coastal Walking Trail, Marino; (**f**) rock climbing in Morialta Conservation Park; (**g**) cycling in Brownhill Creek Recreation Park; and (**h**) sweat-track workouts at Victoria Park.

Using Norton's [45] study as the baseline, a sample size of 19 was required to detect changes at α = 0.5 and power = 0.8. Although 23 participants commenced the program, only 17 achieved full participation with pre- and post-intervention testing.

As with Norton's [45] study, participants were tested 1 week immediately pre- and 1 week post-study using the same protocols for a range of physical health variables.

Psychological variables were also assessed for this GEx intervention, although not in the Norton [45] study.

The major variables assessed included: blood pressure (BP), measured according to the technique recommended by the American Heart Association [47]; height was measured with the subject in light clothing and bare feet using the stretch stature method [48]; weight where subjects were weighed in minimal clothing, following an 8 hour fast and after voiding; body mass index (BMI) was then derived from the height and weight measures; girth was taken at the level of the narrowest point between the lower rib and the iliac crest when viewed from the front; hip girth was taken at the level of the greatest posterior protuberance of the buttocks; the waist–hip ratio (WHR) of subjects was determined by dividing the waist girth by the hip girth; grip strength using an isometric dynamometer (Takei Kiki, Tokyo, Japan); total cholesterol was measured using finger-tip blood samples from 8-hour fasted patients; aerobic fitness (mL·kg−1·min−1) was predicted using a non-gas analyzed sub-maximal test conducted on an electroncally braked cycle ergometer (Ergoselect 200). The average heart rate (HR) in the final 15 s of each workload was used to construct a regression line for each person. The regression line was extrapolated mathematically to their age-predicted maximal HR (HRmax). On this basis, an estimate was made of the power output (Wmax) they would have achieved at HRmax, and the corresponding oxygen uptake was calculated using: VO2max (mL·kg−1·min<sup>−</sup>1) = ([Wmax/9.81] <sup>×</sup> 60 <sup>×</sup> 2 + [3.5 × Weight])/Weight. Prior to testing, the validity and reliability of tests were assessed using 5–7 repeated tests on the same subject (Table A1, Appendix A).

To assess that sufficient levels of PA were achieved, Polar brand HR monitor watches were used, supplemented by self-reported ratings of perceived exertion [49] and activity diaries. Participants were instructed to program measured VO2max and HRmax values into the Polar S610 watch [50]. The watch uses this data and with its proprietary software estimates EE, accounting for subject gender. Crouter and colleagues [51] found that using actual measured values for VO2max and HRmax resulted in a 4% error (SD ± 10%) in EE.

Instructors provided leadership, instruction, feedback, and guidance during the critical early phase of the activities where participants are more likely to drop out [52]. Many of the outdoor and recreational activities were such that participants were undertaking them for the first time or had not undertaken them since childhood.

The psychological assessment for wellbeing was measured using the self-administered questionnaire: Personal Wellbeing Index—Adult (PWI-A [53]). Self-efficacy was measured using the questionnaire: The Physical Exercise Self-Efficacy Scale [54]. Participants' depression, anxiety and stress were measured using the DASS21 questionnaire [55].

Participants in this study met the criteria for classification as insufficiently active (PA level < 150 min/week) by completing one Active Australia Survey [46], a 7-day recall questionnaire. It is recommended by the Department of Health [56] that adults 'accumulate 150 to 300 min (2 <sup>1</sup> <sup>2</sup> to 5 h) of moderate intensity PA or 75 to 150 min (1 <sup>1</sup> <sup>4</sup> to 2 <sup>1</sup> <sup>2</sup> h) of vigorous intensity PA, or an equivalent combination of both moderate and vigorous activities, each week.' National and state-level surveys have consistently found that approximately half of all adults in Australia do not meet the minimum guidelines [57].

Participants' pre-intervention PA level averaged 84 min/week (range 0–148 min/week). This placed them in a risk factor category for low PA patterns being, on average, in about the lowest third of PA levels among adult South Australians [58]. Participants were mostly aged in their 40s or 50s (48.3 ± 10.2 years) and had poor cardiorespiratory fitness (mean ± SD, VO2max = 25.4 ± 10.6 mL/kg/min), with many showing other risk factors such as hypertension (29%) and high cholesterol (47%; including those on prescription cholesterol-reducing medication).

Average BMI for participants was 30.2 kg·m−<sup>2</sup> pre-intervention (range 23.1–46.2 kg·m−2). Low levels of PA and high body fatness levels significantly increase the risk for chronic conditions such as diabetes and metabolic syndrome, and developing coronary heart disease [59].

Descriptive information was calculated for all variables measured. Pre- and post-comparisons within the GEx sample group were made using paired *t*-tests, and those reaching significance (*p* < 0.05) were reported. The original dataset (*n* = 622) for Norton's [45] intervention was used in the analysis of the significance of the pre-post changes in the current cohort. Comparisons with those results were made using repeated measures analysis of variance (ANOVA). Chi squared analysis was used to compare rates of adherence and compliance within and between interventions.

Ethics approval for this project (Ethics Protocol P017-06) was gained from the University of South Australia Human Research Ethics Committee.

#### **3. Results**

#### *3.1. Participants*

Participant pre-intervention data for those that completed the program are shown in Table 2. Mean ages of participants were 48.8 years for males and 47.8 years for females; the youngest and oldest within both groups being 28 and 59 years respectively. The numbers of males (*n* = 8) and females (*n* = 9) in the finishing group were relatively even.


**Table 2.** Participant information pre-intervention.

Mean, standard deviation (SD) and range are shown.

#### *3.2. Adherence and Compliance*

Inquiries were fielded from 197 members of the public with the offer of either a group-focused (a concurrent study not reported here) or outdoor-focused exercise program. Twenty-six screened participants were assigned the outdoor-focused exercise group, with the first exercise session commencing with 22 participants, of which 17 participants (77% adherence) completed the program and returned for post-intervention testing. Withdrawals were due to reported unrelated medical issues, family circumstances and employment commitments.

Data collected from the Polar Heart Rate Monitors (HRMs) were used to assess daily compliance rates, confirmed by PA Diaries and group session attendance records. Of a possible total of 680 participant-days, there were 397 (58%) recorded on the HRMs, being the days on which participants complied with the requirements of the intervention (≥30 min/day of recorded PA). This is a conservative calculation because attendance records showed numerous instances where participants attended the group sessions but either forgot to record the session on their HRM or had technical problems and no recordings were present when downloaded. Using individuals' PA diary records as well as HRM and attendance data resulted in a final compliance rate of 74%.

There was a gradual decrease in compliance for both group and individual days across the first 3 weeks, and compliance was lowest in week 5 (group 59%; individual 29%). The mean rate of compliance on group days was 77%, which was higher than on individual days (46%). Chi squared analysis determined that compliance on group exercise days was higher than expected, but lower than expected on individual exercise days. The difference in compliance between group and individual exercise days was significant (*p* < 0.0001).

Using a second measure of compliance, it was found that of the participants who completed the program, there were 16 (94%) who achieved sufficient levels of PA (≥150 min/week) at post-testing.

#### *3.3. Physical Activity*

Figure 2 shows the daily recorded mean values for exercise heart rate (HR) and estimated energy expenditure (EE) matched to the corresponding group session or day of individual exercise. Mean HR values ranged from 102 to 138 on individual exercise days and from 103 to 134 on group exercise days. The mean energy expenditure (EE) on individual exercise days was 1076 kJ and ranged from 707 kJ to 1531 kJ. On group exercise days, the mean EE was 1539 kJ and ranged from 1088 kJ to 2470 kJ. Values for each session are shown in Table 3.

**Figure 2.** Weekly estimated energy expenditure by group and individual sessions. Estimated energy expenditure measured in kJ recorded during each PA session and averaged for each week of the intervention. Individual and group training days are shown separately. On average, estimated energy expenditure was significantly higher on group training days (*p* = 0.0016). kJ = kilojoules; *n* = 17.


**Table 3.** Program of daily activities.

Mean HR and estimated EE (shown in kJ) recorded for group and individual exercise sessions across the 40-day outdoor PA intervention. HR = heart rate; kJ = kilojoules. *n* = 17.

#### *3.4. Changes to Physical and Physiological Health Following the Intervention*

Changes to values for health and well-being are shown in Table 4. Small (but not significant) absolute decreases were found for weight, BMI and waist.


**Table 4.** Significant changes in pre- and post-intervention measures (*p* < 0.05).

Means and standard deviations (SD) are shown. # Determined by Wilcoxon Signed-Ranks test. <sup>ᑽ</sup> Some results are not included as questionnaires were incomplete.

The change for hip reached statistical significance (*p* = 0.036). Further significant changes were seen for total cholesterol (*p* = 0.026), aerobic fitness (*p* = 0.002), dynamic stability (*p* = 0.038) and all categories of PA minutes (*p* < 0.001). No adverse changes to variables of any category were observed.

Results of the outdoor PA intervention were compared to those of the Norton [45] study using repeat-measures ANOVA to check for any significant intervention x time interaction differences in a range of variables. There were no significant differences between the intervention changes in all but two categories, meaning that the GEx intervention resulted in improvements of a similar nature to those seen following the indoor-based intervention for almost all variables (except grip strength and vigorous PA minutes).

#### *3.5. Changes to Mental Health and Well-Being Following the Intervention*

Although not investigated in Norton's [45] study, of interest for the GEx study was the potential for changes in participant mental health and well-being. This additional investigation was conducted using Personal Wellbeing Index—Adult [53], The Physical Exercise Self-Efficacy Scale [54] and the DASS 21 questionnaire [60]. The GEx intervention enhanced outcomes for four of the five psychological variables, with significantly improved mean scores for well-being (*p* < 0.001), depression (*p* < 0.001), anxiety (*p* = 0.042) and stress (*p* = 0.004). Raw scores for self-efficacy also increased but not to statistical significance (Table 4).

Figure 3a plots the mean changes for well-being and self-efficacy from pre- to post-intervention. Improvements are represented by increased scores. Figure 3b plots the mean changes for depression, anxiety and stress from pre- to post-intervention. Improvements are represented by decreased scores.

**Figure 3.** Changes in participant psychological scores pre- and post-GEx intervention. Chart (**a**) shows pre and post changes in well-being (using the Personal Wellbeing Index—Adult; *n* = 14) and self-efficacy (using The Physical Exercise Self-Efficacy Scale; *n* = 17) where improvements are represented by increased scores; chart (**b**) shows pre-post changes in depression, anxiety and stress (using the DASS21 questionnaire *n* = 17) where improvements are represented by decreased scores.

Although well-being increased significantly (*p* < 0.001) across the outdoor PA intervention (Table 4), no significant intervention x time relationship was detected. Significant relationships were detected between the starting value and the change in value for self-efficacy (*p* < 0.001), depression (*p* < 0.001), anxiety (*p* = 0.007), and stress (*p* = 0.003). This effectively means that the lower a starting score for self-efficacy (or the higher a starting score for depression, anxiety or stress), the greater the likelihood a positive change will occur.

#### **4. Discussion**

This intervention study sought primarily to measure adherence and compliance to a GEx-based program of PA. Secondary aims were to improve the health and well-being of participants and to compare the extent of change against a program that utilized primarily traditional, indoor-based physical activities.

Physical activity interventions may only be successful if participants comply with protocols and adhere to a program. Encouragingly, this GEx intervention recorded similar (77%) adherence when compared with the indoor program (84%), suggesting the potential for strong participant retention with PA programs in green spaces. Adherence is likely to vary with climate and other setting-specific factors; for example, warmer weather and longer daylight hours in an aesthetically pleasing setting may strengthen participation and should be considered when setting a program.

Compliance was also comparable between the GEx (58.1%) and indoor (62.6%) programs. Findings from both interventions suggested future PA interventions might benefit from including more group-based sessions where higher compliance was recorded, compared with individual sessions of exercise. For this study, weekly compliance (≥150 min/week) could be reached by attending the three group sessions only, which may have acted to demotivate participation in individual sessions where compliance was much lower, for example week five (29%).

Further results indicate that similar outcomes (10 of 12) were achieved for the physical and physiological measures. This result would indicate that beneficial PA can be achieved without the need for costly, tailored indoor spaces and equipment, as the majority of the GEx program was conducted in public green spaces, with little or no equipment. Further benefits to participants were reported in the form of psychological measures, all showing an improvement pre- to post-intervention, four of five being significant. Although these results did not have a direct comparator, they would appear to support the growing number of studies [10,15,17,18,32,61–65] showing the potential for GEx programs to improve the health and well-being of participants across a range of measures.

Limitations to this study must be acknowledged, particularly related to sample size. The number of participants was modest (and not to the statistical power calculation) where a larger sample would increase the confidence that the results reflected potential changes in the broader population. Moreover, the mean age of these participants (48 years) was much higher than for the comparative group (35 years). This age difference is likely to influence participants in many ways, such as time availability, motivation, physical and mental condition, and other life circumstances. Additionally, a control group would have improved study design and allowed for direct comparison for the assessments undertaken. A final limitation to acknowledge is that disparate compliance rates (between individuals, or by individuals from week-to-week or in group versus individual sessions) are likely to have resulted in varied impacts on the health and well-being outcomes recorded. Greater consistency in compliance rates among individuals and by individual participants across the program would allow for more confident conclusions to be drawn on the effectiveness of GEx to improve health and well-being.

An informal follow-up at 12 months provided a lot of anecdotal evidence to indicate that some participants had continued to be active in small groups, for example with "weekly outdoor exercise excursions" (email correspondence, 8 April 2013). Participants also reportedly continued to receive the GEx "benefit ... that is both physical and emotional/mental" (email correspondence, 8 April 2013).

#### **5. Conclusions**

In conclusion, with the considerable limitations in mind, this study would appear to support GEx as a viable alternative to other programs by offering the potential for similar health and well-being results when compared with indoor exercise programs. Further, for those seeking psychological benefits from exercise, GEx has provided positive outcomes for almost all participants of this study.

For some, GEx may be a preferred form of activity, particularly for those who have an aversion to joining gyms or clubs, have financial constraints, or have issues with accessing traditional facilities. Green spaces are generally free to use and prevalent in developed cities; however, this is not always the case. A lack of access or other factors such as a real or perceived lack of safety may be a deterrent to participation. A focus by government on creating and maintaining natural outdoor spaces may provide the impetus for people to engage in GEx, a low-cost and effective means of improving physiological and psychological health and well-being when compared with indoor exercise requiring specific facilities and equipment.

It is recommended that further research into GEx be undertaken, particularly to follow up its potential to enhance mental health and well-being and the associated effects on adherence and compliance to PA programs.

**Author Contributions:** Conceptualization, N.G. and S.P.; Methodology, N.G.; Validation, N.G.; Formal Analysis, N.G.; Investigation, N.G. and S.P.; Resources, N.G. and S.P.; Data Curation, N.G. Writing—Original Draft, N.G. and S.P.; Preparation, N.G. and S.P.; Writing—Review & Editing, N.G. and S.P.; Visualization, N.G.; Supervision, S.P.; Project Administration, N.G.

**Funding:** This research received no external funding.

**Acknowledgments:** A deal of thanks go to supervisors Kevin Norton and Scott Polley for the time and effort in overseeing this project and supervising Honors student Nicholas Glover. Thanks also to fellow honors student Ross Hamilton who contributed to much of the logistical workload.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **Appendix A**



#### **References**


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