Atlas›Domain XV · Nature, philosophy, social & rites of passage›Guide 014
Guide XV-014

Nature and park prescriptions

Robert Zarr, Melissa Lem2013Washington DC, USA
A 25 · L 64 · M 1122 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the PaRx five-step prescriber guidance (BC Parks Foundation, Canada) as published on its prescriber page, read alongside the DC Park Rx clinical workflow presented by Robert Zarr (APHA webinar slides, 2017), the NHS Shetland and RSPB Scotland "Nature Prescriptions" leaflet-and-calendar model, and the England Green Social Prescribing national evaluation (Haywood et al., January 2024). Where these differ, the difference is named in the text.

A nature or park prescription is not a psychotherapy. It is a brief, written, personalised recommendation by a health professional that a person spend time in a named natural place doing an activity they choose, with a plan for when and a follow-up. Park Rx America describes itself as a non-profit whose mission is to reduce chronic disease, increase health and happiness and foster environmental stewardship by prescribing nature during routine healthcare [source: American Trails directory listing; Nature Sacred 2019 article]. Robert Zarr, a Washington DC paediatrician, is reported as founder and medical director of Park Rx America and founder of DC Park Rx, which went live on 1 July 2013 [source: APHA 2017 slides; Nature Sacred 2019]. PaRx is Canada's national nature prescription programme run by the BC Parks Foundation; its own page credits Dr Melissa Lem as co-founder and says park prescriptions began as a grassroots movement in the United States [source: PaRx About]. A launch date of 30 November 2020 appears in a PaRx update title [uncertain: not verified]. In Shetland, NHS Shetland and RSPB Scotland piloted Nature Prescriptions at one surgery in 2017 and extended them to all ten Shetland GP practices in October 2018, using an RSPB leaflet and a calendar of seasonal local activities [source: Common by Nature, RSPB, 2018].

Core idea of change, as the programmes state it: a specific, written health recommendation from a trusted professional makes it more likely that a person actually goes outdoors, and regular contact with nature is linked with better mood, lower stress and fewer chronic-disease risks [source: PaRx prescribers page; Nature Sacred 2019]. Zarr frames time in nature as a "dose" written alongside medicines [source: Nature Sacred 2019]. Evidence status in one line: a systematic review and meta-analysis of nature prescription programmes found benefits for blood pressure, depression and anxiety scores and walking, but "Most studies have a moderate to high risk of bias" [source: Nguyen, Astell-Burt, Rahimi-Ardabili and Feng, Lancet Planetary Health 7(4) e313-e328]. The England green social prescribing evaluation reported pre-post improvements in wellbeing and anxiety in routine data, mostly among people with mild to moderate needs, without a control group [source: GSP evaluation summary 2024].

What the psychotherapist does: (a) where their licence and the programme allow, writes the prescription themselves; (b) more often, uses the same steps inside therapy (assessment of nature contact, personalising, scheduling, follow-up), coordinates with the client's physician, who prescribes and handles any medical or exercise questions, or with a social prescribing link worker; (c) prepares and debriefs the client; and (d) works with what the outdoors means to the client. PaRx says any licensed health-care provider can register, giving nurses, physicians and physiotherapists as examples; whether psychologists, counsellors or psychotherapists are eligible is not stated, so confirm with PaRx directly [source: PaRx prescribers page]. Related guides: 015 green social prescribing; 022 blue care and open-water swimming; Domain X 196 cold-water immersion; Domain II 040 behavioural activation.

2. Framework

No source gives a session count or session length for a nature prescription; it is delivered inside an ordinary appointment and reviewed at the next one [source: PaRx prescribers page; APHA 2017 slides]. The phases below follow the DC Park Rx workflow and the PaRx five steps; phase labels are this guide's own [synthesis].

  1. Identify need and current pattern. Goal: decide whether nature time fits the client's problems and learn how much time they already spend in green or blue space. DC Park Rx starts by recognising a health need and reviewing the daily routine [source: APHA 2017 slides]. Move on when the client is interested and no medical question is unanswered.
  2. Assess readiness and safety. Goal: gauge willingness (DC Park Rx step) and screen for medical, mobility, allergy, trauma or safety issues that change the plan. PaRx says people with medical concerns should consult a health-care provider [source: PaRx prescribers and About pages]. Move on when the client wants to try and any medical issue has been routed to their physician.
  3. Personalise and choose a place. Goal: match a nearby, accessible place and an activity to the client's interests and abilities; PaRx suggests shifting a familiar activity outdoors; DC Park Rx looks up parks with the patient in real time [source: PaRx; APHA 2017]. Move on when there is one named place and one named activity the client likes.
  4. Write and schedule. Goal: a written prescription and a diary commitment. PaRx says written prescriptions are better received than verbal advice and asks the patient to write the commitment down like an appointment [source: PaRx prescribers page]. Any amount or frequency is set by the client and, where exertion is involved, the physician; this guide gives no targets [synthesis].
  5. Link and support. Goal: reduce barriers; connect to a PaRx Connector, a social prescribing link worker or a community provider if wanted; the GSP evaluation found that link workers accompanying people to a first session helped engagement [source: PaRx; GSP evaluation summary 2024].
  6. Follow up and review. Goal: check what happened at the next appointment and revise [source: PaRx step 4; APHA 2017]. Criteria for continuing: the client is going, finds it helpful, and it is safe. Criteria for changing: repeated non-attendance, a new barrier, a safety concern, or a negative experience to process.
  7. Integrate and make meaning. Goal: fold nature contact into the therapy plan (behavioural activation, mood monitoring, grief work) and explore its meaning to the client [synthesis].

3. Guiding principles

  • Nature as a pillar of health. PaRx asks prescribers to add nature time whenever they counsel on diet, exercise and sleep [source: PaRx]. Practical meaning: raise it as a normal part of the care plan, not as an alternative to treatment.
  • Personalise. Recommend nearby places and familiar activities; make it work for all abilities [source: PaRx]. Practical meaning: the client's interests choose the activity, not your preferences.
  • Client-set goals. PaRx says meaningful contact with nature counts and goals can be set by the patient [source: PaRx]. Practical meaning: no fixed dose from you; the client decides what counts.
  • Write it down. Written prescriptions are better received than verbal advice [source: PaRx]. Practical meaning: give the client something on paper or in the portal.
  • Be specific. Zarr links the motivating effect to specificity and framing as medicine [source: Nature Sacred 2019]. Practical meaning: name the place, the activity and when, not "get outside more".
  • Schedule and follow up. [source: PaRx steps 3 and 4]. Practical meaning: put it in the diary and ask about it next session every time.
  • Model it, within limits. PaRx's fifth step is that prescribers show they act on the advice themselves [source: PaRx]. Practical meaning for a therapist: brief, purposeful self-disclosure only, if it serves the client [synthesis].
  • Equity and access. Low-income communities are least likely to have access to green space [source: UNSW news on Nguyen et al.]; GSP barriers included poverty, transport, equipment, cultural fit and inaccessible spaces [source: GSP evaluation summary 2024]. Practical meaning: ask about cost, transport, safety and belonging before assuming a park is usable.
  • Range of options. The Shetland leaflet offers activities for different health conditions, confidence levels and social preferences [source: Common by Nature 2018]. Practical meaning: offer solitary and social, near and far, active and still options.
  • Medical questions go to medicine. [source: PaRx About]. Practical meaning: no exercise, diet or medicine advice from you; route to the physician or a qualified exercise professional [synthesis].
  • Check the provider. PaRx Connectors operate independently, and PaRx advises making your own assessment before referring [source: PaRx]. Practical meaning: vet any group or guide before you refer.
  • Active linking beats passive referral. Accompanying a first visit and keeping consistent contact improved engagement [source: GSP evaluation summary 2024]. Practical meaning: make the first step as concrete and supported as possible.
  • Scope of practice. Practical meaning: prescribe only if your licence and the programme allow; otherwise recommend within therapy and coordinate with the client's physician [synthesis].
  • Confidentiality and boundaries outdoors. Practical meaning: if you ever meet a client outdoors, contract in advance about being seen, touch, travel and weather; see 015 and the walk-and-talk guides [synthesis].
  • Concepts held lightly. Ideas such as biophilia or the healing power of nature ("Nature to guide the healing process", Zarr, Nature Sacred 2019) are the programmes' framing; present them as such, neither as fact nor dismissed [synthesis].

4. Intervention inventory

The programmes publish a short prescribing sequence rather than a set of techniques. Items 1-11 and 15-16 follow the published steps; the remaining items are therapist-side procedures, marked [synthesis] where no source describes them.

1. Nature-contact history and daily routine review

  • Purpose and when: first step in DC Park Rx (review the daily routine and current time in green space) [source: APHA 2017]. Use when low mood, stress, isolation, inactivity or indoor-bound routines are part of the formulation.
  • Steps: (1) Ask where the client spends a typical weekday and weekend. (2) Ask about any green or blue places they pass, used to visit, or loved as a child. (3) Ask what stops them going now. (4) Note any places with painful associations. (5) Summarise the pattern back.
  • Example language (illustrative): "Walk me through a usual day. Where, if anywhere, do you see trees, water or sky? Was there ever a place outdoors that felt like yours?"
  • Watch for: shame about inactivity; outdoor places linked to assault, accidents or bereavement; agoraphobia or panic outdoors; neighbourhood safety fears. It is working when the client names at least one place with a positive or neutral pull.

2. Readiness assessment

  • Purpose and when: DC Park Rx asks the clinician to gauge willingness to spend more time outdoors before writing anything [source: APHA 2017]. Use before every prescription.
  • Steps: (1) Ask how important and how confident the client feels about getting outside. (2) Reflect ambivalence without pushing. (3) If readiness is low, agree only to keep the idea open and revisit. (4) If moderate or high, move to personalising.
  • Example language (illustrative): "On a scale you choose, how much do you want this, and how sure are you that you could do it this week? What would move that up a notch?"
  • Watch for: agreement to please you; depression-driven hopelessness that will make failure likely (shrink the step); a sense of being fobbed off with a park instead of treatment. Working when the client volunteers their own reasons.

3. Medical, safety and access screening

  • Purpose and when: PaRx says people with medical concerns should consult a health-care provider [source: PaRx About]. Use before any plan involving exertion, heat, cold, water, remote places or new medicines.
  • Steps: (1) Ask about heart or lung conditions, epilepsy, pregnancy, mobility or falls, severe allergies (stings, pollen), medicines that affect heat or balance, and current eating-disorder or over-exercise patterns. (2) If any apply or the client is unsure, ask them to check the plan with their physician; with consent, write to the physician. (3) Agree any limits the physician sets. (4) Screen for disordered eating or compulsive exercise; if present, refer to a registered dietitian or eating-disorder service (in the US, the National Alliance for Eating Disorders) [synthesis].
  • Example language (illustrative): "Before we fix anything, is there any health condition or medicine your doctor would want to know about if you were out walking or by water? I'd like you to run this past them."
  • Watch for: the plan turning into an exercise or weight-loss programme; you are not prescribing intensity, duration or frequency of exertion. Working when medical questions are answered by the right person.

4. Presenting the rationale

  • Purpose and when: PaRx frames nature time as a health recommendation alongside diet, exercise and sleep, cites links to lower stress and better mood, and notes possible benefit to the environment [source: PaRx]. Use once readiness is present.
  • Steps: (1) Link the suggestion to the client's own goals. (2) Give a short, honest evidence statement (benefits for mood and anxiety in studies with moderate to high risk of bias). (3) Invite questions. (4) Make clear it adds to, not replaces, therapy or medicine.
  • Example language (illustrative): "There's reasonable research linking regular time in nature with lower stress and better mood, though the studies aren't perfect. I'd like to add it alongside what we're already doing, not instead of it."
  • Watch for: over-selling; clients on medication hearing "nature instead of pills" (never advise starting, stopping or changing a medicine). Working when the client can say why it might help them.

5. Personalising place and activity

  • Purpose and when: PaRx step 2; the Shetland leaflet offers options for different conditions, confidence levels and social preferences [source: PaRx; Common by Nature 2018].
  • Steps: (1) List what the client already enjoys indoors (reading, music, coffee, phone calls, drawing, birdwatching, prayer). (2) Ask which could happen outside. (3) Ask whether they prefer company or solitude, still or moving, busy or quiet places. (4) Choose one activity and one place together.
  • Example language (illustrative): "You said you read every evening. Is there a bench or a garden where you could read some of the time instead?"
  • Watch for: choosing something aspirational rather than likely. Working when the client says "I could actually do that".

6. Moving a familiar activity outdoors

  • Purpose and when: PaRx suggests shifting familiar activities outdoors [source: PaRx]. Use for low-energy or depressed clients who cannot add a new activity.
  • Steps: (1) Pick a routine the client already does reliably. (2) Find the smallest change that adds outdoor contact (taking a call outside, eating lunch near trees, using a route past water). (3) Rehearse the first occasion.
  • Example language (illustrative): "What's one thing you already do most days that could be done with a bit of sky over your head?"
  • Watch for: the change slipping because nothing anchors it; pair it with an existing cue. Working when it happens without effortful planning.

7. Finding a nearby, accessible place together in session

  • Purpose and when: DC Park Rx reviews park options with the patient in real time via a park-finder linked from the electronic record; PaRx asks prescribers to help patients find accessible green spaces close to home [source: APHA 2017; PaRx].
  • Steps: (1) Open a map or the programme's park directory with the client. (2) Check distance, transport, cost, toilets, paths, step-free access, lighting and how busy it is. (3) Note opening times and seasonal closures. (4) Pick a first and a back-up place.
  • Example language (illustrative): "Let's look at the map together. Which of these could you reach without it becoming a big expedition?"
  • Watch for: physical, sensory or wheelchair access; personal safety for women, LGBTQ+ and racialised clients in some spaces; cultural belonging (GSP noted activities were not always culturally appropriate) [source: GSP evaluation summary 2024]. Working when the client can picture getting there.

8. Co-writing the written prescription

  • Purpose and when: PaRx provides registered prescribers with a prescription file and provider code; DC Park Rx records the park, frequency, duration and activities, and Park Rx examples name an activity, a park and how often [source: PaRx; APHA 2017; Washington State Parks Park Rx page].
  • Steps: (1) If you are a registered prescriber, use the programme's form; otherwise write a plain therapy-plan note. (2) Write the named place, the named activity and when the client intends to go, in their words. (3) Leave amounts the client chooses; if exertion is involved, any amount comes from the physician or a qualified exercise professional, not from you. (4) Give the client a copy.
  • Example language (illustrative): "I'll write it down so it's as real as any other part of your care. You tell me the wording for when you'll go."
  • Watch for: a therapist-imposed dose; prescriptions the client experiences as homework they can fail. Working when the client keeps the note somewhere visible.

9. Scheduling it as an appointment

  • Purpose and when: PaRx step 3 asks the patient to write the commitment down like an appointment [source: PaRx].
  • Steps: (1) Ask the client to open their calendar now. (2) Enter the first occasion with place and activity. (3) Add a reminder. (4) Agree a back-up slot for bad weather or a bad day.
  • Example language (illustrative): "Let's put the first one in your diary now, with a back-up in case the day goes wrong."
  • Watch for: vague slots ("sometime at the weekend"). Working when the entry exists before the client leaves.

10. Barrier problem-solving

  • Purpose and when: GSP found poverty, transport costs, lack of equipment and worsening mental health limited participation, and that buddy schemes, transport funding and equipment helped retention; PaRx lists partner offers to reduce barriers [source: GSP evaluation summary 2024; PaRx About].
  • Steps: (1) Ask what could get in the way: money, transport, clothing, childcare, carers' duties, weather, safety, energy, symptoms. (2) For each, generate one workaround. (3) Check programme partner offers or local free schemes. (4) Identify a companion if the client wants one.
  • Example language (illustrative): "If this doesn't happen, what will most likely have stopped it? Let's sort that one now."
  • Watch for: structural barriers you cannot problem-solve away; acknowledge them and adjust the plan rather than implying the client lacks willpower. Working when the main barrier has a named fix.

11. Seasonal activity calendar

  • Purpose and when: RSPB Scotland's calendar of seasonal local activities underpins the Shetland prescriptions; Park Rx offers a pocket calendar for self-prescribers [source: Common by Nature 2018; Washington State Parks Park Rx page]. Use for longer-term work, seasonal low mood, or clients who lose interest.
  • Steps: (1) Obtain a local programme's calendar if one exists; otherwise build one with the client. (2) Mark seasonal events the client might enjoy (blossom, migrating birds, autumn colour, frost, long evenings). (3) Choose one per month or season to look forward to [synthesis].
  • Example language (illustrative): "What happens outdoors around here at different times of year that you'd like to catch?"
  • Watch for: dark months when access and safety fall; plan indoor-to-outdoor bridges such as a window view or a lit park. Working when the client anticipates something ahead.

12. Linking to connectors, link workers and nature-based providers

  • Purpose and when: PaRx lists Connectors, trained practitioners who help patients act on a prescription; in England, link workers connect people to nature-based groups after a "what matters to you" conversation, and "active" link working (accompanying a first session) helped engagement; taster sessions inside mental health trusts were used to build referral routes [source: PaRx; GSP evaluation summary 2024]. Use when the client wants structure, company or a group (conservation, gardening, care farming, walking groups, outdoor talking therapies). See 015 green social prescribing.
  • Steps: (1) Ask whether the client would prefer a group or a guide. (2) With consent, contact the GP practice's link worker or the local provider directory. (3) Share only what the client agrees to. (4) Ask whether someone can meet the client at the first session. (5) Set a date to hear how it went.
  • Example language (illustrative): "Some people find it easier with a group and someone to meet them at the gate. Would you like me to ask the link worker whether that's possible?"
  • Watch for: stretched link-worker capacity and unclear referral routes, which the evaluation reported [source: GSP evaluation summary 2024]; clients with complex needs placed in groups whose staff lack training in risk. Working when the client attends a first session.

13. Vetting a nature provider or guide before referral

  • Purpose and when: PaRx says its Connectors operate independently and advises prescribers to make their own assessment before referring [source: PaRx]. Use before any referral to a group, guide or outdoor therapist. The checklist is [synthesis].
  • Steps: (1) Ask what the activity involves and who leads it, and what training they hold. (2) Ask for their safety, safeguarding, first-aid, weather and incident procedures and insurance. (3) Ask how they handle distress, disclosures and dropout. (4) Ask about access and cost. (5) Ask how they communicate with referrers.
  • Example language (illustrative, to a provider): "Before I suggest your group to a client, could you tell me how you handle someone becoming distressed during a session, and who to contact afterwards?"
  • Watch for: providers making clinical claims beyond their training; no written safety or safeguarding procedure. Working when you can describe the session to the client accurately.

14. Outdoor safety briefing

  • Purpose and when: prepare the client for ordinary outdoor risks; qualitative only, routed to the programme's and public-health bodies' guidance [synthesis].
  • Steps: (1) Weather and terrain: check the forecast, dress for it, keep to paths suited to mobility, and have a turn-back plan. (2) Ticks: UKHSA advises keeping to clear paths, light-coloured clothing, repellent, checking skin after being outdoors, prompt removal with fine-tipped tweezers or a tick tool, and contacting a GP or NHS 111 for a spreading red rash or flu-like illness after a bite [source: UKHSA "Be tick aware"]. (3) Allergies: carry any prescribed emergency medicine. (4) Hydration and sun: take water and cover. (5) Tell someone where you are going if alone, and carry a charged phone. (6) Water: for any plan near or in water, cover cold-water shock, hypothermia and drowning in plain terms, ask about heart conditions, epilepsy, pregnancy and medicines, route the client to their physician and to published water-safety guidance (for example RNLI, the Outdoor Swimming Society or Swim England) [uncertain: not verified], and see 022 and Domain X 196; this guide gives no water, cold or exposure parameters.
  • Example language (illustrative): "A few practical things so the outdoors doesn't bite back, literally in the case of ticks."
  • Watch for: anxious clients for whom a long hazard list becomes a reason not to go; keep it short and proportionate. Working when the client has a simple plan they can recite.

15. Follow-up review

  • Purpose and when: PaRx step 4 and DC Park Rx both build in follow-up at the next appointment [source: PaRx; APHA 2017].
  • Steps: (1) Ask early in the next session whether it happened. (2) If yes: what was it like, what did you notice in body, mood and thoughts, and what next. (3) If no: curious, non-blaming analysis of what got in the way, then a smaller or different step. (4) Update the written plan.
  • Example language (illustrative): "Last time you planned to sit by the canal on Thursday. How did that go, either way?"
  • Watch for: the client hiding non-attendance; respond with interest, not disappointment. Working when the client reports some benefit or useful information either way.

16. Documentation and logging

  • Purpose and when: DC Park Rx records the prescription in the treatment or preventive medicine section of the record and gives a patient summary; PaRx asks registered prescribers to log prescriptions on its site [source: APHA 2017; PaRx].
  • Steps: (1) Record place, activity, intended timing, barriers, safety points and follow-up date in your notes. (2) If registered with a programme, log as it instructs, sharing no more client information than the programme requires. (3) Copy to the physician only with consent.
  • Example language (illustrative): "I'll note this in your record like the rest of your plan. Nothing goes to the park programme that identifies you."
  • Watch for: programme logging forms asking for more than you can share under your confidentiality rules [synthesis]. Working when notes let you follow up precisely.

17. Integrating with behavioural activation [synthesis]

  • Purpose and when: use the outdoor plan as an activation target for depression, withdrawal or avoidance (see Domain II 040).
  • Steps: (1) Add the outdoor activity to the activity schedule. (2) Have the client rate mood and sense of pleasure or achievement before and after, on whatever simple scale your BA protocol uses. (3) Review the ratings together. (4) Grade upward only in what the client chooses to do, not in exertion.
  • Example language (illustrative): "Let's treat Thursday's bench time as an experiment: note your mood just before and just after."
  • Watch for: the plan becoming another chore; perfectionism. Working when ratings show a lift the client notices themselves.

18. Debriefing the experience and working with meaning [synthesis]

  • Purpose and when: after the client has been outdoors, especially if something strong came up.
  • Steps: (1) Ask for a sensory account first (what they saw, heard, smelled). (2) Then feelings and thoughts. (3) Ask what the place reminded them of. (4) Link to therapy themes (loss, belonging, safety, childhood, faith). (5) Hold the programmes' ideas (nature as healer, connection to the living world) as framings the client may or may not share.
  • Example language (illustrative): "Before we get to whether it 'worked', tell me one thing you noticed out there that you wouldn't have noticed indoors."
  • Watch for: grief triggered by places shared with someone who has died; climate distress or eco-anxiety (groups such as the Climate Psychology Alliance and the Good Grief Network exist; describe them as their organisers do and check their current offer) [uncertain: not verified]; spiritual experiences, where the Cultural Formulation Interview's spirituality, religion and moral traditions module can help. Working when the outdoors becomes material for therapy, not just a task.

19. Children, young people and families [synthesis]

  • Purpose and when: PaRx publishes paediatric handouts (ADHD, allergies and asthma, mental health, school success and others) [source: PaRx]. Use in child and family work.
  • Steps: (1) Plan with the parent or carer and get the child's assent. (2) Choose places and activities suitable for the child's age and needs. (3) Cover tick checks for children and supervision near water and roads. (4) Review as a family.
  • Example language (illustrative, to a child): "If you could choose any outdoor place to go with your family, where would it be?"
  • Watch for: safeguarding concerns (unsafe neighbourhoods, neglect); outdoor time used as punishment or a substitute for assessment of ADHD or learning needs. Working when the family goes together and enjoys it.

20. Supporting self-prescription and client-led goals

  • Purpose and when: PaRx says goals can be set by the patient; Park Rx offers a pocket calendar for people who want to self-prescribe [source: PaRx; Washington State Parks Park Rx page]. Use as therapy ends or for clients who dislike being prescribed to.
  • Steps: (1) Hand authorship to the client. (2) Ask them to write their own plan for the coming season. (3) Review it once, then let it run.
  • Example language (illustrative): "You know now what works for you outside. Want to write your own version for after we finish?"
  • Watch for: plans that quietly lapse after discharge; build in a self-review date. Working when the client continues unprompted.

21. Coordinating with the physician

  • Purpose and when: the physician is the right prescriber for medical or exertion questions and, in many systems, the registered nature prescriber [source: PaRx; NHS England green social prescribing page]. Use whenever a medical, mobility, exercise or medicine question arises.
  • Steps: (1) Get written consent. (2) Send a short letter: the goal, the client's chosen activity and place, any questions. (3) Ask the physician to add any medical limits or to write the formal prescription. (4) Incorporate their reply. [synthesis for steps]
  • Example language (illustrative): "Would you be happy for me to write to your GP so the outdoor plan sits alongside the rest of your care?"
  • Watch for: the client changing medication because "nature is helping"; never advise starting, stopping or changing a medicine. Working when both plans agree.

22. Therapist modelling and dual roles [synthesis]

  • Purpose and when: PaRx's fifth step is that prescribers act on nature recommendations themselves [source: PaRx]. For a therapist this touches self-disclosure and, if you also lead outdoor groups or guide, multiple relationships (APA Ethics Code Standard 3.05, APA Ethics Code).
  • Steps: (1) Disclose your own nature habits only briefly and only if it helps the client. (2) Do not recruit clients into groups you run without discussing the role change. (3) If you work outdoors with clients, contract about confidentiality when seen in public, touch (consent before and during, a right to stop, never sexual), travel, weather plans, insurance and liability, and training as the relevant certifying body sets it.
  • Example language (illustrative): "I do something like this myself, but what matters is what works for you."
  • Watch for: the client feeling they must match your enthusiasm. Working when the plan stays theirs.

5. Handling problems

The programme sources say little about clinical difficulties; except where a source is tagged, the guidance below is [synthesis].

  • The client doesn't go (non-adherence). Treat it as data. Ask what happened just before the planned time; shrink the step (doorstep, window, nearest tree); move it next to an existing routine (item 6); check that a structural barrier such as cost, transport, caring duties or safety has not been missed (GSP lists poverty, transport and equipment as barriers [source: GSP evaluation summary 2024]).
  • Stuck or flat: goes but feels nothing. Expect this in depression. Separate doing from feeling; use before-and-after ratings (item 17); vary the place or add company; check that the activity is chosen, not dutiful.
  • Resistance: "Being told to go to the park is patronising." Validate it. Make clear this adds to treatment, offer it as optional, and let the client set the goal (PaRx says goals can be patient-set [source: PaRx]). Explore whether the reaction reflects past experiences of being dismissed by services.
  • Overwhelm or panic outdoors. Pause the plan; assess for panic disorder, agoraphobia or trauma cues; build a graded exposure plan within a recognised protocol with consent and safety steps, starting from places the client chooses; avoid remote or crowded places until the client is ready.
  • Places tied to trauma or loss. Choose a different place; if the client wants to return to a meaningful place (a shared walk with someone who has died, an assault site), plan it as grief or trauma work with preparation, support and a debrief, and an exit plan.
  • Personal safety and belonging. Some clients, including women alone, racialised, disabled and LGBTQ+ clients, may not feel safe or welcome in particular green spaces. Believe the concern, choose busier or staffed places, consider a group or buddy (buddy schemes helped retention [source: GSP evaluation summary 2024]), and do not frame avoidance as cognitive distortion when the risk is real.
  • The plan drifts into exercise, weight or diet goals. Re-centre on contact with nature, not exertion. Screen for disordered eating or compulsive exercise and refer to a registered dietitian or an eating-disorder service (in the US, the National Alliance for Eating Disorders). Exercise questions go to the physician or a qualified exercise professional (Domain II 040 for activation framing).
  • Medical red flags. New chest pain, breathlessness, fainting, falls, a spreading rash or flu-like illness after a tick bite [source: UKHSA "Be tick aware"]: tell the client to seek medical care and stop the plan until cleared.
  • Water-based plans. If the client wants to swim or immerse, do not give any water, cold or exposure guidance. Discuss cold-water shock, hypothermia and drowning in plain terms, ask about heart conditions, epilepsy, pregnancy and medicines, and route to the physician and published water-safety guidance; see 022 and Domain X 196.
  • Medication changes. If a client wants to stop medicines because nature is helping, do not advise; refer back to the prescriber.
  • Rupture: the client hears "go outside" as dismissal of their suffering. Name it, apologise for any misattunement, re-affirm the main treatment, and ask whether the outdoor plan should be parked.
  • Seasonal collapse. Dark, cold or wet months reduce access; adjust to the season (item 11), use window views, lit parks or indoor plants as bridges, and assess for seasonal mood patterns.
  • Eco-anxiety or climate grief surfaces. Make space for it without treating it as irrational; consider groups run for this purpose (e.g. Climate Psychology Alliance, Good Grief Network; check what each offers) [uncertain: not verified].
  • Provider problems. If a client reports an unsafe, exploitative or poorly run group, stop referring, discuss with the client, and raise it with the link worker or commissioner; PaRx Connectors operate independently of BC Parks Foundation [source: PaRx].
  • Scope and eligibility. If you are not eligible to register with a programme, work through the physician or link worker (item 21) rather than issuing a document that looks like a formal prescription.
  • Confidentiality when outdoors or meeting clients by chance. Agree in advance how to handle being seen together or meeting in a park; if you accompany a client, contract about privacy, touch, travel, weather plans and insurance (item 22); see 015 and the walk-and-talk guide.
  • Risk during outdoor time. For a client at risk of suicide or self-harm, include solitary and remote outdoor plans in the risk assessment and safety plan; give crisis contacts (988 in the US; Samaritans 116 123 in the UK and Ireland).

Sources

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