Outdoor complementary therapies

1. Introduction

Version followed: outdoor complementary therapies treated as a category of community nature-based activity (outdoor yoga, tai chi and qigong, mindfulness in green space), framed by green social prescribing as the National Academy for Social Prescribing (NASP) and Natural England describe it in England; referral and safety steps from the NASP / Thrive Green Social Prescribing Practitioner Guidance (v5); nature-based mindfulness components as Djernis et al. (2019) catalogue them. The specific yoga, tai chi or qigong style is whatever the client's instructor teaches; this guide does not teach those systems (cross-refer the Domain X yoga and tai chi guides and the Domain XIII guides on their religious and spiritual roots).

This is not a single therapy. It is a family of practices that community providers run outdoors, and that health professionals and social prescribing link workers may connect people to. Green social prescribing is defined by NASP as helping people take part in nature-based activities to improve mental and physical health, with link workers or other professionals connecting people to community groups "based on what matters to that person" [source: NASP, What is Green Social Prescribing?]. The published GSP activity lists name community gardening, walking schemes, conservation volunteering, outdoor arts, wild swimming and green gyms "among others"; outdoor yoga, tai chi and mindfulness are not named on those pages, and Natural England's programme post shows yoga in a park only as a photograph [source: NASP; Natural England blog 2022]. Whether a given local scheme lists these activities is therefore [uncertain: not verified] and must be checked locally.

Core idea of change, as attributed: the activity (a movement or attention practice) and the natural setting are combined. Djernis et al. (2019) use attention restoration theory as their main framework: nature offers "soft fascination" that lets attention rest, which they propose may help inexperienced meditators who otherwise lose concentration or feel overwhelmed; stress reduction is named as a further pathway. Social contact in a group and regular routine are additional mechanisms GSP programmes emphasise [source: NASP; synthesis]. For the psychotherapist, change comes less from the class than from how it is chosen, prepared for, debriefed and given meaning within therapy [synthesis].

Evidence status in one line each: nature-based mindfulness showed a medium pre-post effect across 25 studies, but the authors stress "the generally low quality of the studies" and call the field "in its infancy" [source: Djernis et al. 2019]. Structured outdoor nature-based interventions reduced depressive mood and anxiety in RCTs, with less evidence for physical health [source: Coventry et al. 2021]. Yoga "appears as safe as usual care and exercise" in RCTs, though safety reporting is often poor [source: Cramer et al. 2015]. The cross-Government GSP programme reports statistically significant improvements in mental health and wellbeing; its design detail is [uncertain: not verified] [source: NASP summary].

2. Framework

The psychotherapist's work runs alongside the provider's own referral pathway. The NASP / Thrive practitioner guidance sets that pathway out for providers in six stages, and the therapist's phases below are mapped onto it [source: Green SP Practitioner Guidance v5; mapping is synthesis].

Provider pathway (as the guidance describes it):

Before referral: the provider gives link workers a service description; referral forms carry contact details, health and social information, identified risks, an agreed limit on contact attempts, and other professionals involved.
Participant information: an accessible welcome pack, with optional taster visits, videos or a short phone call.
Risk assessment: written, completed before the person attends.
Start of access: induction and a one-to-one conversation about needs and adjustments.
Throughout access: ongoing assessment, regular check-ins, dynamic risk management, communication with link workers.
End of access: a planned ending, signposting to community options, evaluation.

Need levels: the guidance uses a five-level mental health framework. Nature-based interventions typically support people at Levels 1 to 3 (from loneliness, low mood or low motivation, through needing psychological therapy, short-term medication or monitoring, to more complex needs across several areas); Level 0 has no delivery, and Level 4 "typically sits within clinical rather than community settings" [source: Green SP Practitioner Guidance v5].

Therapist phases [synthesis, built on the above]:

Assessment and fit. Goal: decide whether an outdoor practice serves the client's goals now, and at what need level. Move on when the client is interested, the need level fits community delivery, and medical or safety questions have been routed.
Preparation and referral. Goal: choose a provider, check its safeguards, share information with consent, rehearse the first visit. Move on when a start date and a back-up plan exist.
Participation and integration. Goal: attendance becomes part of the treatment plan; sessions debrief experience and link it to therapy goals; brief nature-based mindfulness may be practised in therapy if the therapist is trained. Move on when attendance is stable or when obstacles have been worked through.
Review. Goal: compare against the client's own aims and any wellbeing measure; adjust, change provider or stop. Move on when the client chooses to continue independently or to end.
Ending and maintenance. Goal: avoid a "cliff edge" when a funded place ends; plan independent continuation and signposting [source for cliff edge: Guidance v5].

Session count and format: no source gives a number of therapy sessions for this work; provider programmes set their own lengths, and the guide gives no activity durations or frequencies. Format is usually individual therapy in the room with the activity happening elsewhere, or therapy partly outdoors (see walk-and-talk and blue care guides in this family; 022 for water; Domain X 196 for cold-water immersion).

3. Guiding principles

What matters to the client leads. [source: NASP] Practical meaning: start from the client's interests and values, not from the therapist's favourite practice.
Match the need level to the setting. [source: Guidance v5] Practical meaning: community classes suit Levels 1 to 3; acute risk or Level 4 needs belong with clinical services, with the class as an adjunct at most.
Stay within competence and scope. [source: Guidance v5 notes practitioners are not generally qualified to advise on medication; synthesis] Practical meaning: the therapist does not teach yoga or tai chi without a recognised teaching qualification and insurance, gives no exercise prescription, and never advises starting, stopping or changing a medicine.
No exercise prescription. [source: WHO 2020 guidelines exist; synthesis] Practical meaning: WHO publishes physical-activity guidelines covering adults, older adults, people with chronic conditions or disability and pregnancy, with the message that some activity is better than none; amounts and progressions come from the client's physician or a qualified exercise professional. Frame participation as behavioural activation (Domain II 040).
Safety is dynamic. [source: Guidance v5] Practical meaning: risk is reviewed before attendance and whenever circumstances change, not just once.
Check providers before referring. [source: Guidance v5; TCUGB; BWY] Practical meaning: safeguarding policy, DBS checks, written risk assessment, first-aid training, appropriate insurance and a recognised teaching body.
Access is part of the intervention. [source: Guidance v5] Practical meaning: transport, toilets, shelter, sensory, cognitive and physical access and carer support are planned, not assumed.
The outdoor frame must be contracted. [source: Jordan & Marshall 2010] Practical meaning: confidentiality, timing, being seen and weather are agreed before any therapy moves outside.
Consent to touch, before and during, with a right to stop; never sexual. [synthesis] Practical meaning: clients are prepared to decline hands-on adjustments in classes; the therapist does not use touch outdoors without an explicit contract.
Concepts are attributed. [synthesis] Practical meaning: "soft fascination", qi, prana or a tradition's spiritual claims are described as their authors hold them, neither asserted nor dismissed.
Collaboration with consent. [source: Guidance v5] Practical meaning: share what the provider needs for safety, with the client's agreement, and agree an escalation route.
Planned endings. [source: Guidance v5] Practical meaning: the end of a funded place is anticipated in therapy, with a continuation plan.
Record non-engagement too. [source: Guidance v5 advises providers to record non-access, attrition and early leaving] Practical meaning: a missed class is clinical information, not failure.
Dual roles managed explicitly. [source: APA Ethics Code, Standard 3.05] Practical meaning: a therapist who is also the client's yoga or tai chi teacher assesses whether the multiple relationship risks impairing objectivity or exploiting the client, and usually refers to another instructor.

4. Intervention inventory

The sources describe provider-side referral stages and catalogue nature-based mindfulness components; they do not set out therapist procedures. The therapist-side procedures below are built on those stages and components and are marked [synthesis] where no source states them. Interventions 8 to 10 are delivered by the therapist only if trained in mindfulness teaching; yoga, tai chi and qigong themselves are delivered by qualified instructors.

1. "What matters" matching conversation

Purpose / when: at assessment, when a client is isolated, low in motivation, stressed or curious about outdoor practice; to find an activity that fits values rather than a generic suggestion [source: NASP "what matters" framing; steps synthesis].
Steps: (1) Ask what the client enjoyed outdoors or in movement at any point in life. (2) Ask what they want more of: calm, company, body confidence, routine, time outside. (3) List options without ranking them: outdoor yoga, tai chi or qigong in a park, a mindfulness walk, or other GSP activities such as gardening or walking groups. (4) Ask about barriers: cost, travel, mobility, caring duties, fear of groups, body image, faith concerns. (5) Agree one option to explore, or none.
Example language (illustrative): "Before I suggest anything, tell me about a time you felt at ease outside, or in your body. What was happening?"
Watch for: compliance ("whatever you think"), shame about fitness or weight, a wish to please. Working when the client names the option in their own words and can say why it matters to them.

2. Need-level and suitability check

Purpose / when: before referral, to decide whether a community class is appropriate now [source: Guidance v5 five-level framework].
Steps: (1) Place the client's current need on the guidance's levels (Level 1 low mood or loneliness; Level 2 needing therapy, short-term medication or monitoring; Level 3 complex needs across several areas; Level 4 usually clinical settings). (2) Complete current risk assessment by standard practice, including suicide and self-harm risk. (3) If Level 3, check involvement of specialist or community mental health teams and whether the client needs a carer or staggered start. (4) If capacity to consent is in doubt, address it before referral. (5) Decide: refer now, refer later, or keep the activity as a longer-term goal.
Example language (illustrative): "Right now the most important thing is getting you through this week safely. A tai chi group is a good idea for later, and I'd like us to come back to it."
Watch for: pressure from the client or family to use a class instead of needed treatment; active risk. Working when the decision is shared and documented.

3. Health, medical and safety screen with routing

Purpose / when: before any movement-based or outdoor activity [synthesis; Guidance v5 notes practitioners are not generally qualified to advise on medication and should focus on side effects that affect safety].
Steps: (1) Ask qualitatively about heart or breathing conditions, epilepsy, pregnancy, recent surgery or injury, joint problems, balance, dizziness, medications that affect balance, alertness or heat tolerance, allergies (including insect stings and pollen), and skin sensitivity to sun. (2) Do not interpret or advise on any of this; ask the client to check with their GP or physician, or a qualified exercise professional, before starting. (3) Encourage the client to tell the instructor about relevant conditions at induction. (4) Note that WHO guidelines exist for adults, older adults, people with chronic conditions or disability and pregnancy, and that the physician sets what is right for them.
Example language (illustrative): "I'm not the right person to say what's safe for your heart. Could you ask your GP about gentle outdoor classes, and tell the instructor too?"
Watch for: a client minimising symptoms to avoid being "stopped". Working when medical questions have gone to the right person before the first class.

4. Screen for compulsive exercise and disordered eating

Purpose / when: before recommending any movement practice, and whenever exercise talk sounds driven, punitive or weight-focused [synthesis].
Steps: (1) Ask how the client feels if they miss planned activity, and whether movement is used to compensate for eating. (2) Ask about recent weight change, restriction or bingeing, without setting any weight or food target. (3) If concerns arise, refer to an eating-disorder service or registered dietitian and their GP; give the National Alliance for Eating Disorders as a support resource. (4) Reframe any outdoor practice around attention, rest and connection rather than calorie burn.
Example language (illustrative): "When you skip a session, what goes through your mind? Does it ever feel like you have to make up for something you ate?"
Watch for: pride in pushing through pain, rigid rules. Working when the client can describe the practice without reference to burning or earning food.

5. Provider evaluation before referral

Purpose / when: whenever the therapist recommends or refers to a specific class or group [source: Guidance v5; TCUGB Standards and Ethics policy; BWY].
Steps: (1) Ask for the provider's service description. (2) Check for a safeguarding policy, DBS checks for staff and volunteers, a whistleblowing policy, and a written risk assessment completed before attendance [Guidance v5]. (3) Check that instructors hold first-aid training [Guidance v5; TCUGB requires first aid (CPR) training; BWY notes many policies will not cover a claim if no trained first aider is present]. (4) Check insurance: TCUGB requires "the appropriate levels of insurance"; BWY notes venues increasingly ask for public liability and professional indemnity cover. (5) Ask about the instructor's teaching body and training (e.g. TCUGB instructor membership; BWY teacher membership); quality frameworks such as the Green Care Quality Mark are cited by the guidance. (6) Ask about wet-weather arrangements, shelter, toilets and how sessions end. (7) Record what was checked.
Example language (illustrative, to a provider): "I'm a therapist and my client is interested in your class. With their consent, could you tell me about your induction, risk assessment and what happens if someone becomes distressed?"
Watch for: providers making medical or curative claims, no safeguarding policy, reluctance to share basics. Working when the client attends a provider whose safeguards are known.

6. Consent-based referral and information sharing

Purpose / when: when referring directly or via a social prescribing link worker [source: Guidance v5 referral contents].
Steps: (1) Agree with the client exactly what will be shared. (2) Include what the guidance asks for: contact details, relevant health and social information, identified risks, an agreed number of contact attempts if the client does not respond, and other professionals involved. (3) Keep psychotherapy content out unless needed for safety. (4) Agree who the provider contacts if worried, and how the therapist will hear about non-attendance (with consent).
Example language (illustrative): "The group needs to know about your asthma and who to call if you're unwell. They don't need to know what we talk about here. Is that okay?"
Watch for: over-sharing that stigmatises the client; consent given under pressure. Working when the client has read or heard what is being sent.

7. Preparing for the first visit

Purpose / when: after referral, before the first session; especially for social anxiety, agoraphobia or low confidence [source: Guidance v5 welcome pack and taster visits; steps synthesis].
Steps: (1) Go through the welcome pack together: meeting point, route, public transport, toilets, shelter, drinks. (2) Suggest a taster visit, video or a short call with the instructor if offered. (3) Plan clothing for weather, water to drink, and what to do if the weather turns. (4) Rehearse arriving, introducing oneself, and saying "I'll sit this one out" or "please don't adjust me". (5) Agree a small first step (attending, or just visiting the site) and a plan if it goes badly.
Example language (illustrative): "Let's walk through it: you get off the bus, you see the group by the bandstand. What's the first thing you'd want to say?"
Watch for: catastrophic predictions, avoidance disguised as practical problems. Working when the client attends, or visits the site, and can describe what happened.

8. Behavioural-activation framing and activity scheduling

Purpose / when: for low mood and withdrawal; the outdoor class becomes a values-linked activity on the schedule (cross-refer Domain II 040) [synthesis].
Steps: (1) Link the activity to a value the client named in intervention 1. (2) Place it on the activity schedule as the client chooses, without the therapist setting frequency, duration or intensity. (3) Ask the client to note mood before and after, and anything they noticed outdoors. (4) Review at the next session: what helped, what got in the way. (5) Solve barriers rather than raising targets.
Example language (illustrative): "You said you want to feel part of something again. Where in your week could the park group sit, if you decide to go?"
Watch for: all-or-nothing thinking after one missed class. Working when the client links attendance to mood or connection in their own observations.

9. Brief sensory awareness practice outdoors or at a window

Purpose / when: to introduce nature-based mindfulness in session, for clients new to meditation or who find inward-focused practice overwhelming; Djernis et al. describe guided use of the senses in natural settings as a recurring component, and the authors propose nature may help inexperienced meditators [source: Djernis et al. 2019; steps synthesis]. Therapist must be trained in mindfulness teaching.
Steps: (1) Ask consent and offer eyes open. (2) Invite the client to notice, one at a time, what they can see, hear, smell and feel on the skin (air, sun, ground). (3) When the mind wanders, invite a return to one sense. (4) Close by asking what they noticed. (5) Offer it as an optional home practice in a park, garden or by a window.
Example language (illustrative): "Keep your eyes open. Just notice the sounds out there, near and far. You don't need to name them or like them."
Watch for: hay fever or allergy, intrusive memories triggered by a smell or sound, self-criticism about "doing it wrong". Working when the client reports some settling or curiosity, or can return attention more easily.

10. Mindful walking

Purpose / when: for restless, anxious or ruminative clients who find sitting practice hard; mindful walking with attention to breath and body sensations is a recurring component in the review [source: Djernis et al. 2019; steps synthesis]. Done in session only after contracting the outdoor frame (intervention 13).
Steps: (1) Choose a safe, level, familiar route; check access needs. (2) Walk at the client's own pace. (3) Invite attention to the feet on the ground, then to breathing, then outward to the surroundings. (4) Allow silence; pause to talk if the client wishes. (5) Debrief once seated or at the end.
Example language (illustrative): "Let's just walk for a bit without talking. Notice your feet on the path. If you want to stop and say something, we stop."
Watch for: pain, breathlessness, uneven ground, fear of being seen, heat or cold. Working when rumination eases or the client starts noticing surroundings spontaneously.

11. Seated nature-focused attention (open monitoring of natural stimuli)

Purpose / when: for clients who can sit comfortably outdoors and want a quieter practice; the review includes sitting on a bench to observe trees and a creek, meditating on forest, wind and sounds, and open monitoring of natural stimuli [source: Djernis et al. 2019; steps synthesis].
Steps: (1) Agree a sheltered, safe spot with a seat and an exit. (2) Invite the client to let attention rest on what moves: leaves, water, clouds, birds. (3) Invite noticing without labelling or judging, and gently returning when caught in thought. (4) Close by asking what drew attention and how the body feels now. (5) Offer the same practice at a spot near home.
Example language (illustrative): "Let your eyes rest on whatever is moving out there. No need to hold onto anything. When a thought pulls you away, the trees are still there to come back to."
Watch for: drowsiness, dissociation, cold or discomfort, insects. Working when the client describes attention resting with less effort.

12. Informal mindfulness in an activity the client already does

Purpose / when: when formal practice is unappealing; the review notes informal mindfulness fits everyday activities such as walking a forest trail, and that gardening, nature walks and other activities were combined with mindfulness in included programmes (the informal-versus-formal difference was not statistically significant) [source: Djernis et al. 2019; steps synthesis].
Steps: (1) Identify an outdoor routine: dog walk, allotment, walk to work. (2) Choose one moment within it for noticing with the senses. (3) Agree a cue (a gate, a tree, the first step outside). (4) Review what was noticed next session.
Example language (illustrative): "When you open the allotment gate, could you take a moment just to notice the smell of the soil before you start work?"
Watch for: the practice becoming another chore. Working when the client reports spontaneous moments of noticing.

13. Contracting the outdoor therapeutic frame

Purpose / when: before any part of therapy moves outside (walking sessions, sitting in a park, meeting at a class site); Jordan and Marshall (2010) identify contracting around confidentiality and timing, and the mutuality and asymmetry of the relationship, as the central frame issues outdoors [source: Jordan & Marshall 2010 abstract; steps synthesis].
Steps: (1) Discuss being seen: what the client will say if they meet someone they know, and whether the therapist acknowledges them. (2) Agree how to pause conversation when people pass. (3) Agree start and end points, timing and who keeps time. (4) Agree a weather plan: what conditions cancel or move the session indoors, and how each party is told. (5) Agree travel arrangements (no shared car journeys unless explicitly contracted and insured [synthesis]). (6) Agree on touch: none, or exactly what (e.g. a steadying hand on rough ground), with consent asked each time. (7) Agree emergency arrangements: phone, first aid, nearest exit. (8) Check that professional indemnity insurance covers outdoor work. (9) Record the contract and revisit it.
Example language (illustrative): "If we bump into someone you know, what would you like to happen? I can carry on walking as if we're just two people out for a walk, or step away."
Watch for: the session drifting into social chat, blurred endings, the client feeling exposed. Working when both parties can describe the agreed frame and it holds in practice.

14. Outdoor safety briefing (weather, terrain, ticks, hydration)

Purpose / when: before first attendance and seasonally; routes the client to the provider's own safety guidance [synthesis; ticks from UKHSA].
Steps: (1) Discuss weather qualitatively: sun, heat, cold, wind, rain, and clothing and shelter. (2) Discuss terrain: uneven ground, slopes, wet grass, and the client's balance. (3) Encourage bringing water to drink. (4) Give UKHSA tick advice: stick to clear paths and avoid brushing vegetation, cover skin, consider repellent, check body, clothes and pets soon after being outdoors, remove an attached tick promptly with a tick tool or fine-tipped tweezers, and contact the GP or NHS 111 if a spreading "bullseye" rash or flu-like or nerve symptoms follow a bite. (5) Allergies: medicines or plans as advised by their own clinician. (6) Any water-based or water-side activity: no timings or temperatures are given here; cover cold-water shock, hypothermia and drowning risk qualitatively, the need for medical screening (heart conditions, epilepsy, pregnancy, medications), and route to published guidance from the RNLI, the Outdoor Swimming Society or Swim England [uncertain: not verified]; cross-refer 022 (blue care, wild and open-water swimming) and Domain X 196 (cold-water immersion).
Example language (illustrative): "The park sessions run in most weather. What would you need to feel comfortable if it's cold or wet? And when you get home, a quick tick check is worth doing."
Watch for: health anxiety escalating from tick information; give it proportionately. Working when the client has a practical plan and is not deterred.

15. Preparing for touch and hands-on adjustment in classes

Purpose / when: before yoga or tai chi classes where instructors may physically adjust posture; especially for clients with trauma histories [synthesis].
Steps: (1) Explain that some instructors use hands-on correction. (2) Explore how the client feels about being touched by a teacher. (3) Rehearse saying no before class and in the moment. (4) Affirm the client's right to stop or leave at any point; touch should never be sexual. (5) Discuss what to do if touch felt wrong, including the provider's safeguarding route and the teaching body's complaints process.
Example language (illustrative): "You can tell the teacher at the start, 'No hands-on adjustments for me, please.' You don't have to give a reason."
Watch for: freezing, difficulty refusing authority figures, disclosure of past abuse. Working when the client feels able to set the limit and does so.

16. Trauma-sensitive preparation for body-based practice

Purpose / when: for clients with trauma, dissociation, panic or chronic pain, before yoga, tai chi, qigong or body scans outdoors [synthesis].
Steps: (1) Ask which body sensations, postures, breath instructions or eyes-closed practices feel unsafe. (2) Plan options: eyes open, staying near the edge of the group, skipping postures, using the surroundings as an anchor. (3) Practise a grounding skill in session the client can use in class. (4) Agree a plan for leaving early and contacting someone.
Example language (illustrative): "If a pose or a breathing instruction starts to feel too much, what could you do in that moment? Looking at the trees is always allowed."
Watch for: panic with breath work, flashbacks in certain postures, dissociation. Working when the client completes classes with fewer episodes, or uses the plan successfully.

17. Post-class debrief

Purpose / when: at the session after each class or practice, to link experience to therapy goals [synthesis].
Steps: (1) Ask what happened, in sequence. (2) Ask about body, mood and thoughts before, during and after. (3) Ask about the group and the instructor. (4) Identify links to therapy themes (self-criticism, connection, control). (5) Agree whether to continue, adjust or stop.
Example language (illustrative): "Walk me through it from when you arrived. When did you notice your shoulders drop, if they did?"
Watch for: comparison with others, perfectionism, a disappointing first experience generalised to all practices. Working when the client draws their own links between practice and goals.

18. Outcome monitoring and review

Purpose / when: at agreed review points; the guidance notes providers may use validated tools such as the Warwick-Edinburgh Mental Wellbeing Scale and should record non-access, attrition and early leaving [source: Guidance v5; therapist steps synthesis].
Steps: (1) Agree the client's own markers (sleep, mood, contact with others, time outdoors). (2) Use whatever validated measure the service uses, under its licence terms. (3) Record attendance and non-attendance without judgement. (4) Review together and decide to continue, change or stop.
Example language (illustrative): "Let's look at how things have moved since you started. What's different, if anything, and what's the same?"
Watch for: improvement attributed only to the class while other problems go unaddressed. Working when change shows in the client's own markers.

19. Collaboration and escalation with provider and link worker

Purpose / when: throughout participation; the guidance asks providers to liaise with other health professionals involved, for consistency and escalation [source: Guidance v5; steps synthesis].
Steps: (1) With consent, agree a named contact at the provider and at the link worker service. (2) Agree what each party does if the client is distressed, at risk, or stops attending. (3) Keep communication minimal and safety-focused. (4) Update the risk picture when the client's need level changes, since the guidance calls for immediate review then.
Example language (illustrative, to an instructor): "If you're ever worried about her at a session, please contact the link worker, and if it's urgent, emergency services."
Watch for: the provider being drawn into a therapeutic role it is not equipped for. Working when everyone knows the route and it is used appropriately.

20. Accessibility and adjustment planning

Purpose / when: for clients with disability, chronic illness, sensory or cognitive needs, caring duties or limited money; the guidance asks providers to state transport options and physical, sensory and cognitive access, and to consider attendance with a carer, extra induction or a staggered start [source: Guidance v5; steps synthesis].
Steps: (1) Identify the client's specific access needs. (2) Check the provider's description against them; ask about seated or adapted versions of practices. (3) Plan transport and cost, including free or funded GSP places where they exist. (4) Arrange a carer or buddy if wanted (NASP publishes a Nature Buddies toolkit for volunteer programmes). (5) Ask the client to discuss adjustments in the provider's one-to-one at induction.
Example language (illustrative): "Would a chair-based tai chi group suit you better, or would you like to ask whether this one can adapt the moves?"
Watch for: the client carrying all the burden of access, or giving up after one inaccessible session. Working when the client attends without avoidable strain.

21. Working with meaning: nature, place, culture and tradition

Purpose / when: when the practice touches identity, faith or place, for example a client uneasy about yoga's or tai chi's religious or philosophical roots, a migrant client connecting with landscape, or a client whose experience outdoors includes racism or harassment [synthesis].
Steps: (1) Ask what the practice and the place mean to the client. (2) Where faith or tradition is involved, use the DSM-5-TR Cultural Formulation Interview and its supplementary module on spirituality, religion and moral traditions. (3) Describe concepts such as qi, prana or "soft fascination" as their traditions and authors hold them, without endorsing or dismissing them. (4) If the client wishes, support a conversation with their own faith leader. (5) If difficulty centres on religious or spiritual conflict, consider the DSM-5-TR Religious or Spiritual Problem, coded Z65.8 (ICD-10-CM, Unbound Medicine); DSM-5-TR wording [uncertain: not verified]. Cross-refer Domain XIII guides.
Example language (illustrative): "Some people feel tai chi is part of a tradition they want to honour, some keep it purely as movement, and some feel it clashes with their faith. Where do you sit?"
Watch for: the therapist's own enthusiasm or scepticism shaping the client's view. Working when the client can choose a practice that fits their values.

22. Managing a dual role when the therapist also teaches

Purpose / when: when a therapist is also a qualified yoga, tai chi or mindfulness teacher and considers teaching a client, or a client joins the therapist's public class [source: APA Ethics Code Standard 3.05; TCUGB and BWY membership requirements; steps synthesis].
Steps: (1) Check that teaching qualifications, teaching-body membership, first aid and insurance cover both roles; therapy indemnity may not cover teaching and vice versa. (2) Assess, per Standard 3.05, whether the multiple relationship could reasonably be expected to impair objectivity, competence or effectiveness, or risk exploitation or harm. (3) Default to referring the client to another instructor. (4) If proceeding, agree in writing how confidentiality, payment, touch, group settings and endings will be handled, and consult a supervisor.
Example language (illustrative): "I do teach yoga, but I think it would muddle our work here if I were your teacher too. Let me suggest a couple of teachers you could try."
Watch for: the client seeking extra contact, discomfort in group settings, the therapist's financial interest. Working when roles stay distinct and the client's therapy is unaffected.

23. Planned ending and continuation plan

Purpose / when: before a funded or time-limited place ends; the guidance warns against a "cliff edge" and asks providers to signpost to local nature and social connection options [source: Guidance v5; steps synthesis].
Steps: (1) Note the end date early. (2) Ask what the client wants to keep: the place, the people, the practice. (3) Identify free or low-cost continuations: independent practice in a local park, a community class, a walking group, volunteering. (4) Plan for winter or bad-weather gaps. (5) Link the plan to relapse prevention in therapy.
Example language (illustrative): "The course finishes next month. What would you miss most, and how might you keep a bit of it going?"
Watch for: grief at losing the group, dropping all activity at the end. Working when the client has a concrete, self-chosen plan.

5. Handling problems

The sources do not address most of these problems; responses are [synthesis] unless a source is given.

Stuck or ambivalent client: go back to intervention 1; ask what would have to be true for the client to try; offer a smaller step (visiting the site, watching a class) [synthesis].
Non-attendance: treat it as information, as the guidance treats non-access and attrition [source: Guidance v5]; explore practical barriers (weather, transport, cost, caring duties) first, then emotional ones (shame, social fear); avoid moralising.
"Resistance" or scepticism about "nature cures": agree that evidence is modest and of mixed quality (Djernis et al. describe generally low study quality); frame the activity as an experiment the client evaluates for themselves [synthesis].
Overwhelm, panic or dissociation during a practice: use the plan from interventions 15 and 16; in session, stop the practice, open eyes, orient to the surroundings, ground with feet and breath at the client's own pace; review what triggered it and adapt [synthesis].
Being seen or breach of privacy outdoors: follow the contract from intervention 13; if it breaks down, return indoors and revisit consent [synthesis; frame issue per Jordan & Marshall 2010].
Rupture over boundaries outdoors (session ran long, too personal a conversation, an unplanned touch): name it at the next session, take responsibility for the therapist's part, re-contract [synthesis].
Weather cancels sessions: use the agreed weather plan; keep an indoor or window-based alternative ready (intervention 9); consider seasonal planning in advance [synthesis].
Injury, pain or a medical event: client follows the provider's first-aid and emergency arrangements and seeks medical care; the therapist does not advise on physical treatment; review whether the activity remains suitable with the client's clinician [synthesis].
Compulsive exercise or eating concerns emerge: pause encouragement of the activity, reassess (intervention 4), refer to an eating-disorder service, registered dietitian or GP, and give the National Alliance for Eating Disorders as a support resource [synthesis].
Health anxiety about ticks or allergies: give UKHSA information proportionately once; avoid repeated reassurance; treat health anxiety itself if it persists [synthesis; ticks per UKHSA].
Client wants the class to replace therapy or needed medical care: revisit need level (intervention 2); Level 4 needs belong in clinical settings per the guidance [source: Guidance v5].
Crisis or suicidal risk disclosed outdoors or to an instructor: follow standard risk assessment and the agreed escalation route (intervention 19); give crisis resources (988 in the US; Samaritans 116 123 in the UK and Ireland; emergency services if life is at risk) [synthesis].
Eco-anxiety or climate grief surfaces in nature practice: explore it as a meaningful response; if the client wants a group, consider groups as their organisers publish them (e.g. Climate Psychology Alliance, Good Grief Network) [uncertain: not verified]; cross-refer the ecopsychology guides in this family [synthesis].
Faith or cultural conflict about yoga or tai chi: use intervention 21; offer secular-framed alternatives such as mindful walking or gardening; never pressure participation [synthesis].
Unsafe or unprofessional provider (medical claims, no safeguarding, inappropriate touch): stop referring, support the client to use the provider's safeguarding route and the teaching body's complaints process, and make a safeguarding referral where required [synthesis; safeguarding policy requirement per Guidance v5].
Funding ends or the group closes: move to intervention 23 early; acknowledge the loss [synthesis].

Sources

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