Attorney Articles | A New Way of Life The Ethics of Embracing the Outdoors

Articles by Legal Department Staff

The Legal Department articles are not intended to serve as legal advice and are offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in the article.

A New Way of Life The Ethics of Embracing the Outdoors

In these physically-distant times, therapists and patients alike are seeking alternative ways of connecting with patients beyond telehealth. In this article, CAMFT Staff Attorney Kristin W. Roscoe, J.D. guides MFTs through the legal and ethical issues that arise when conducting walk and talk therapy.

A New Way of Life: The Ethics of Embracing the Outdoors

The Therapist
September/October 2020
Kristin W. Roscoe, JD (CAMFT Staff Attorney)

The renowned naturalist John Muir understood the restorative effect of being outdoors when he said, “I only went out for a walk, and finally concluded to stay out till sundown, for going out, I found, was really going in.”1 As I sit here to write this article, I am covered in mosquito bites and nursing lingering aches after having taken a week to go backpacking in the Sierra Nevada. Anyone who has taken a walk around the neighborhood, along the beach, or through a local park knows that you don’t have to take my extreme approach to “going in” to get the same restorative benefit from nature. It remains one of the few safe, easily accessible outlets for most of us in the age of COVID-19, which is why therapists are also looking to the outdoors as an option for their patients to more safely “go in.” While taking therapy outdoors may have fewer health risks these days, there are numerous legal and ethical risks to take into consideration before incorporating nature into your practice.2

Psychotherapy in the Great Outdoors
Incorporating the outdoors into therapy comes in as many forms as there are species of trees—from “wilderness therapy” and “nature therapy” to “adventure therapy” and “walk and talk therapy.”3 Walk and talk sessions typically occur in a public place. As such, they may facilitate collaborative engagement by providing a shared experience to enhance the therapeutic alliance.4 Movement can bring energy to the session thanks to the release of endorphins, which may be helpful to the collaborative process.5 Experiencing the outdoors may offer “healing and restoration through a sense of freedom, space and openness.”6 As wonderful as a contemplative stroll through a sunlight-dappled park may sound, before commencing walk and talk therapy clinicians should research the appropriateness of this type of psychotherapy for their specific patient population.7

Nature, Take It or Leave It
The outdoors is not for everyone. Allergies, physical limitations, and weather constraints should be taken into account by both therapist and patient before stepping outdoors. A therapist who is considering incorporating the outdoors into their work should be familiar with its therapeutic effectiveness and its benefits to the patient. Every patient is different, and not all patients will benefit from walk and talk therapy. Even if it is the patient who proposes taking the treatment outdoors, the therapist should consider the patient’s presenting issue(s), history, physical and mental well-being, and sociopsychological situation.

Information regarding the efficacy of walk and talk therapy and the risks/benefits associated with this modality should be included in the Informed Consent paperwork. Putting the patient on notice at the outset of treatment that walk and talk therapy may be something the therapist recommends will allow the patient an opportunity to have an early discussion about that possibility.

In this conversation, the therapist should be prepared to explain to the patient why taking a session outdoors may be beneficial, or why it may not be. Regardless, the therapist must ensure that the patient understands the choice is theirs alone. By taking a mindful approach to this conversation, the therapist can be sure that the patient knows they have the right to decline the offer without fear of retaliation. Further, the patient should be encouraged to speak with their physician first to make sure they are physically able to engage in outdoors based therapy.

Therapists who wish to incorporate the outdoors into their practice should consider other potential disrupters. As a result of the COVID-19 pandemic, the former president of CAMFT’s Board of Directors, Cathryn Leff, LMFT, began treating patients on the patio connected to her home office. Leff and her patients “have had to contend with garbage trucks, lawnmowers, and noisy motorcycles that interrupt the flow.” Despite this, Leff reports that her good-natured patients find humor in such interruptions. An additional issue is contending with the unpredictability of the weather. In those areas of the state where temperatures can jump into the hundreds during the summer months (I’m looking at you Borrego Springs, where it was 121 degrees recently) or dip into hypothermic levels during the winter (hey there, South Lake Tahoe), therapists should exercise their best judgment before stepping outdoors so as not to endanger their or their patients’ well-being.

Practice Pointers

  • In the Informed Consent Form or Disclosure Statement include a provision that the therapist may recommend incorporating outdoors-based psychotherapy into the patient’s treatment.
  • Be prepared to discuss the risks and benefits of outdoors-based psychotherapy, including that most things (e.g., weather, limits to confidentiality, potential hazards) are outside the therapist’s control.
  • The patient should consult with their physician to ensure that they are medically healthy enough for outdoors-based psychotherapy and to assess whether there are any actions, such as taking allergy medication or bringing an inhaler, that the patient should take before or during psychotherapy outdoors.
  • If the patient has a serious medical condition, such as a bee allergy, it will be helpful for the therapist to know so they can be prepared to dial 911 if necessary.
  • Liability insurance may not cover all psychotherapy services provided outdoors, so therapists should consult with their insurance company to see if their policy includes coverage from both a malpractice and a general liability standpoint for the type of work they propose to do with their patients outdoors. Most CAMFT members have professional liability insurance with CPH & Associates, which has indicated that it covers walk and talk therapy. Members are strongly encouraged to contact their insurance company directly for more information.

The Trees Have Eyes: Patient Confidentiality
Therapists are compelled both by statute and by the CAMFT Code of Ethics to maintain patient confidentiality regardless of whether the session is in a traditional office setting, on the front patio of your home, or in a local park.8 Once a therapist leaves the confines of their office, maintaining confidentiality becomes more difficult. In the office, a white-noise machine may be all that’s needed to ensure that what is said can only be heard by therapist and patient. Once outdoors, the risks to confidentiality increase exponentially since it is no longer a controlled environment.

In her outdoors practice, President Leff reminds patients that she has no control over someone stopping by her home to distribute a flyer, drop off a package, or try to sell her something—it’s not as though there is a “big sign saying ‘THERAPY SESSION IN PROGRESS’” to alert passersby to what she’s up to on her patio. If an interruption occurs, the therapist should consider whether it is appropriate to extend a patient’s session to make up for lost time.

If providing walk and talk therapy in a publicly accessible space outdoors, the therapist must allow for the possibility that they or their patient may encounter someone they know. The therapist should prepare a strategy with their patient for handling such a situation. It may be as simple as greeting the passerby with a wave and a hello and continuing to walk. If a conversation with the passerby occurs, another option could simply be, “Hi, I’m Cathy, a family friend of James’.”

Practice Pointers

  • Remind patients that they still have a right to confidentiality with psychotherapy sessions outdoors. Sessions will be documented and all clinical information will be kept confidential according to California law and/or HIPAA. Be mindful in choosing the location for outdoors-based therapy. A therapist should consider first scouting the location during the proposed session time. A park that is quiet at 2pm on a Tuesday may be bustling at 1pm on a Thursday.
  • Those therapists who provide home-based sessions should consider disclosing to patients whether a household member will be in the home at the same time as a session just in case the family member accidentally pops into a session.
  • Discuss a strategy with the patient for how to handle situations where the therapist or the patient encounters someone they know while engaging in therapy outdoors.
  • Discuss with the patient any necessary disclosures of confidential information in the case of an emergency, such as when an injury occurs.

Maintaining Boundaries
Nature has her own boundaries in the form of physical features such as rivers and mountains. Unfortunately for therapists, professional boundaries do not have physical barriers to serve as reminders before they are crossed. Therapists do not have the option of dropping professional boundaries with patients the moment their sneakers hit the pavement outside. Even when having a session with a patient in the more casual setting of a local park, therapists should still be mindful of any potential for unethical dual relationships to arise. Not all dual relationships are unethical, but any close personal friendship or sexual relationship with a patient certainly leaps over that clear line.9

To avoid a possible fall into the unethical dual relationship chasm, therapists should be clear with their patients about maintaining professional boundaries and managing expectations. Therapists must make clear that while they may be outside of the office and in a space the patient associates with friends and family, they are still in their professional capacity—the service is still psychotherapy, it’s just in a different milieu. Additionally, though the therapy is outdoors and may include walking, therapists should be careful not to assume the role of the patient’s fitness coach or give any advice that is outside the scope of their license.10 By setting clear professional boundaries with patients at the outset, therapists can be prepared when a boundary begins to blur that opens them to the gray zone of dual relationships.

Practice Pointers

  • Set clear professional boundaries with patients whether they are in the office or on top of a steep hill.
  • Monitor conversations and actions to ensure that the therapist is not sliding toward any unethical behavior with the patient.
  • Monitor the patient’s actions to ensure that they remain comfortable in the situation. For example, a patient may feel pressured to race their therapist up a steep hill and not be able to articulate their discomfort with the suggestion at the time given the public location.

In these physically distanced times, where everything seems bewildering and discouraging at best, it is natural to turn to the outdoors to assist patients in the healing process. However, therapists must remain mindful of the legal and ethical obligations that follow them beyond the four walls of their office. Those who wish to incorporate the outdoors into their practice should remember that even though the session is not in the office, the therapist is still providing psychotherapy services. As such, therapists should ensure that they provide their patients with sufficient information so they can make an informed decision as to whether outdoors-based psychotherapy is appropriate. By offering the same level of ethical care that they would provide in the traditional office setting, therapists can avoid potential legal and ethical pitfalls when they’re “going in” with patients outdoors.

Kristin W. Roscoe, JD, is a staff attorney at CAMFT. Kristin is available to answer member calls regarding legal, ethical, and licensure issues.


1 John Muir, John of the Mountains: The Unpublished Journals of John Muir 439 (Linnie Marsh Wolfe ed., 1938 republished 1979).
2 According to scientists’ current understanding as reflected by the Centers for Disease Control, when it comes to the potential for contracting COVID-19, “Indoor spaces are more risky than outdoor spaces where it might be harder to keep people apart and there’s less ventilation.” coping/deciding-to-go-out.html (last accessed July 14, 2020). While there may potentially be fewer risks, there are still risks in having ongoing close contact with a patient outdoors. Therapists should be familiar with and comply with all state, county, and city public health orders pertaining to close contact with a non-family member during the COVID-19 pandemic. Please visit CAMFT’s COVID-19 Resources page for additional information: https://www.
3 Revell & McLeod (2015).
4 Id.
5 Id. Also, remember the wise words of Elle Woods in Legally Blonde, “Exercise gives you endorphins. Endorphins make you happy. Happy people just don’t shoot their husbands, they just don’t.”
6 Id.
7 Your CAMFT membership includes access to the EBSCOhost library of peer-reviewed articles that can help you determine whether walk and talk or another outdoors-based therapy is a good fit for your patients.
8 Bus. & Prof. Code § 4982(m) and CAMFT Code of Ethics § 2.
9 CAMFT Code of Ethics §§ 4.3, 4.4, & 4.5.
10 For more information on the ethics of offering coaching services, please read Coaching vs. Therapy by CAMFT Staff Attorney Sara Jasper, available on CAMFT’s website at https://www.camft. org/Resources/Legal-Articles/Chronological-Article-List/coachingvs- therapy.

This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.