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The New Mental Health Therapy?

Sept. 1, 2006

Looking for some peace of mind that goes beyond the therapist’s couch? The solution could be found in exercise. Now, counselors are providing a new kind of mental health treatment that combines talk therapy with physical exercise that includes everything from walking and hiking to tennis and golf. Clay Cockrell, a New York City licensed social worker, has taken his therapy off the couch and into the great outdoors. “I meet you. We do our session. It’s just much more convenient,” Cockrell said. Antidepressants are taking away business from talk therapy, according to some experts. A recent study found that less than 15 percent of patients had the suggested amount of follow–up care after starting medication. So therapists have to find new ways to keep people interested in talk therapy. Cockrell thinks combining talk therapy with physical exercise might increase the number of people considering talk therapy. “I think we’re becoming a society looking for a quick fix. I go, I take my pill, and I’m better,” he said. “It doesn’t work that way.”

Bonus Benefits

There’s an added bonus in walk and talk therapy — the exercise. Research has shown that even a light workout helps diminish bad moods and relieve pain. “It’s not for everyone, but for those that it works, it really, really works,” Cockrell said.

Some critics, however, say the new type of therapy is unprofessional and doesn’t protect clients’ anonymity. Cockrell, however, disagrees. “I think that it’s still a session. You’re here for 50 minutes to an hour whether we’re in an office or we’re outside walking in the park,” he said to “Good Morning America.” For the clients, exercise therapy seems to hit a lot of birds with one stone: fitness, healing, and a little fun.

The Wall Street Journal Back to top ↑

He is one in a tiny pocket of mental–health practitioners who are combining physical activity and talk therapy. The methods range from strolls to more rigorous “Adventure Therapy” programs, which involve wilderness experiences like rock–climbing and camping. Atlanta psychiatrist Sheldon B. Cohen runs with his patients, while licensed counselor Geri Dube takes her clients on walks around Seattle.

But some prominent doctors are critical of the approach, saying that it can violate professional guidelines meant to establish boundaries and maintain confidentiality. Therapists have also found some real–world risks: Clay Cockrell, a New York social worker who walks with his clients, has witnessed a mugging in Central Park and an explosion during his sessions. Psychotherapist Terri Hengesh, who hikes with her patients in Northern California, has run into snakes on the trail. (If you encounter a snake while walking with your therapist, is it really just a snake?)

The alternative treatments come as mainstream therapists are under pressure, in part because of the success of drugs in treating mental illness. Patients are increasingly opting for medication over talk therapy. Nearly 15% of adults used an antidepressant at least once last year, according to pharmacy benefit manager Medco Health Solutions, up from 12% of adults in 2001. And while drugs are often meant to be used in conjunction with talk therapy, medication is serving as a substitute. A study published this month in the American Journal of Managed Care found that less than 15% of patients received the suggested level of follow–up care after starting antidepressant medication — the U.S. Food and Drug Administration recommends weekly face–to–face visits in the first four weeks. Health insurers often cover just half of the cost of mental–health treatments, leading patients to drop out.

Scientific Benefits Back to top ↑

A number of studies have documented the psychological benefits of exercise. While scientists have long known that a workout can temporarily boost serotonin levels and improve mood, the latest research shows that exercise can have a deeper and more lasting effect. One article in the American Journal of Preventive Medicine last year found a correlation between the intensity of exercise and a reduction in depression. A 2005 study published in the Journal of Neuroscience found that exercise increases the growth of neuronal brain cells, possibly elevating mood permanently. Advocates of the combined approach say that being active during the session helps patients to relax and open up, and some patients say they find it easier to talk while looking forward and walking, rather than staring the therapist in the eye.

Combining therapy with nature and activity isn’t new. In the late 1800s, Sigmund Freud walked with some of his patients through the streets of Vienna and even brought a few of them along on his vacations, says Jacques Barber, associate director of the Center for Psychotherapy Research at the University of Pennsylvania School of Medicine. In later years, Freud moved to an enclosed space to eliminate distractions. Still, up until the 1960s, when antidepressant medications became more common, people with symptoms of depression were often sent to rural retreats were they would garden, chop wood or stroll with doctors. Even today, therapy isn’t limited to offices. A behavioral therapist might take an obsessive–compulsive patient into a dirty train station to confront their worst fears, while others take clients outside, to a park bench or garden.

A Dangerous Combination Back to top ↑

However, some warn that combining sports and therapy can be dangerous. Dr. Barber says that engaging in sports could lead to “multiple relationships” between therapist and patient. “To maintain boundaries, people have to be very cautious,” he says. “If you play tennis with them, where do you stop?”

Peter Kramer, a clinical professor of psychiatry and human behavior at Brown University and author of “Listening to Prozac,” believes that an activity like tennis can add an unwanted element of competition. If a therapist takes too much pleasure in the sport, it can be a problem, he says, “since many patients have had parents who were very competitive, or who were more interested in themselves than in their children.”

Many of the practitioners say it was an intuitive decision. Keith Johnsgard, professor of psychology at San Jose State University and author of “Conquering Anxiety and Depression Through Exercise,” started walking with his patients when he realized that he was less anxious after working out with colleagues at lunch.

Mr. Cockrell in New York hoped to expand his practice by meeting busy patients at the office for a stroll at lunch or on the way home. Now he walks with five clients a day, at $150 for 50 minutes. He recalls “a great session” when a manhole exploded in front of him and a client, forcing them to realize that “you could be zapped at any time.” Another time, Mr. Cockrell and a patient who wanted to be more assertive encountered a woman being mugged. “It was an opportunity to put this into action,” he says. “We both started yelling and the thief ran off.“

amNewYork Back to top ↑

Recovery: Like a walk in the park.

By Farnoosh Torabi

July 2, 2007

Clay Cockrell rings up a new pair of sneakers each month. His job demands it.

As the sole psychoanalyst running Walk and Talk, the 37–year–old conducts therapy sessions on the go in Central Park, Battery Park and throughout Manhattan. “We generally walk in isolated areas. It’s not like people are listening in on our conversations,” said Cockrell, who calls his alternative method “outdoor psychotherapy.” Although if the trees could talk, it would probably be a different story, he admitted.

The concept for Walk and Talk began three years ago after treating patients in his midtown office. “It was actually my wife’s idea,” said Cockrell.

Since then, his client list has more than doubled from 15 to 40 a week. “We’ll walk to their place of business or I’ll meet them at their apartment… The convenience was a big selling point,” he said, adding that appointments are sometimes scheduled in his old midtown office if the discussion is too serious.

Sessions run $100 to $150 for 50 minutes, depending on the time of day. Lunch time and the evening hours after work are, expectedly, the highest in demand and are the most expensive.

Clients range from Wall Streeters to those in film, theater and advertising. Most are referred by friends. Others find Cockrell on his Web site

“I do really well with freelancers. They have that mentality of thinking outside the box,” said Cockrell, a licensed social worker. Going forward, he’d like to see his business expand and be able to employ one more therapist who’d share his philosophy.

Beyond the convenience factor, the benefits of the business, Cockrell said, are two–fold. First, the outdoor therapy sessions allow for more interaction that can support one’s personal growth. “You can talk about how the weather affects your emotion. A lot of my clients don’t get to be outside a lot.”

Take 30–something–year–old Diana Jones (who wished to have her name changed for this article). After a year visiting traditional therapists (couches and all), she now spends her lunch hour every other week with Cockrell in Central Park.

In the past three months, she said Cockrell has helped her better cope with her anxiety issues related to running her own business and starting a family with her husband. “Distractions within the park are actually nice,” she said. “Being [there] we see 40 billion kids … it almost helps [to think it through].”

Then, there’s the physical growth, said Cockrell, since being active is ultimately a healthy thing for the body. Personally speaking, Cockrell’s blood pressure’s gone down and he’s shed about 15 pounds since starting the business. He said being outdoors also forces him to be more on his toes.

“This is harder, I found [for me],” he said. “You really got to be on your game. It’s a dynamic active session. I’m exhausted by the end of the day.”

WebMD Back to top ↑

Exercise is good for the body and the mind. It may improve psychotherapy sessions, too.

By Suzanne Wright

April 11, 2008

Work is a walk in the park for Clay Cockrell. Instead of seeing patients in a traditional office setting, the Manhattan-based licensed clinical social worker practices therapy that combines exercise with psychotherapy -- mostly in Central Park and Battery Park.

"It's very similar to traditional psychotherapy," he tells WebMD, "except you are walking while you are talking about issues. I have found that bringing a little bit of movement enriches the counseling session. My clients are intrigued by the idea and are naturally drawn to being outside."

Kate Hays, PhD, is the author of Working It Out: Using Exercise in Psychotherapy and has incorporated sports psychology into her clinical practice for more than two decades. Now located in Toronto, Hays continues to explore the mind-body connection in her consulting practice, The Performing Edge, and is past president of the American Psychological Association's division of exercise and sport psychology.

Hays says she first encountered the concept of movement and therapy in the early 1980s -- reading such books as Thaddeus Kostrubala's The Joy of Running. The hypothesis is that rhythmic exercise, such as walking, can be conducive to the process of self-discovery.

Hays cites three key reasons for combining exercise and therapy:

  • It encourages a patient to be more physically active for mental and physical reasons.
  • It helps a patient get "unstuck" when confronting difficult issues.
  • It spurs creative, deeper ways of thinking often released by mood-improving physical activity.

"Some patients may become anxious when confronting something difficult in a traditional seated, face-to-face interaction," she says. "Walking in parallel with visual distractions may allow for easier engagement."

Walk and Talk Therapy: Tapping Into Nature's Healing Power Back to top ↑

Cathy Brooks-Fincher, a Brentwood, Tenn.-based licensed clinical social worker with 20 years of experience, has also found this to be true. An avid runner and athlete, she has observed that patients at all levels of fitness can benefit from fresh air and exercise when it comes to processing their feelings. She initially began using walk and talk therapy with teenagers who were having a hard time opening up.

"When I took them into an adjacent park, I found that patients were much more relaxed and the sessions were much more productive," she tells WebMD. "Patients have verified that looking forward rather than directly at a therapist can help them open up.

" Brooks-Fincher also praises the "healing power of nature." She says many patients consider the association of being outdoors with recreation and vacation, two very positive things that most people want to experience more.

"We have a beautiful setting in which to do this, a public park with a paved path that runs along a small river," she says. "There are turtles, deer, birds, and a horse farm; restrooms and water fountains are nice assets. Clients who try walk-and-talk often have very dramatic shifts in their thinking about relationships in their lives."

Licensed clinical social worker Carlton Kendrick, EdM, who is based in Cambridge, Mass., agrees. He got his start using exercise and therapy when working with institutionalized and incarcerated patients in the early 1970s.

"When I got people walking on the grounds, listening to cows mooing and birds singing, having to avoid a rock in the road, engaged in a multi-sensory experience, the result was the patients were much more talkative and relaxed."

Walk and Talk Breakthroughs Back to top ↑

Movement propels people forward -- literally and figuratively.

"Something changes when people warm to this [therapy]," Kendrick says. "They come in their body armor -- their suits -- and when they change their clothing and when they see me in my sweats and sneakers, they loosen up. The literal and metaphorical ability for them to move, to experience freedom and a lessened sense of confrontation, of 'being under the microscope,' that they may predictably feel in my or anyone's office setting.

"The comfort of a patient establishing his or her own rhythm is secure," he continues. "And it's a subtle bond -- we are in sync, we are on an adventure together. Being in nature takes [the session] out of my power base and into the streets and hills. It's much more of an equal turf and provides more parity."

Hays agrees. "At any point in psychotherapy where a patient is at something of an impasse or if a patient is alienated, those are situations I would be likely to offer this as a way through whatever is going on. A patient might be able to view a situation with more clarity, more insight, and make connections which she otherwise might not be able to because of the biochemical effects of being active."

Debbie, one of Cockrell's patients, says she tried standard therapy in the past but praises the benefits of walk and talk."In my experience," she tells WebMD, "taking four walls out of the equation helped me open up and feel more comfortable. He plans the route perfectly; all I have to do is follow his lead, which allows me to get lost in my thoughts and emotions and really work it out without thinking of the ticking clock," says Debbie who asked that only her first name be used. "It allows me to open up more than I would have sitting in a room staring at someone. Also since my blood is pumping, I'm more open to new ideas, my brain is working in a different way."

Walk and Talk Therapy: Is It Right for You? Back to top ↑

Numerous scientific studies have shown the positive effects of exercise on the brain, especially for people with depression.

Brooks-Fincher says that depressed patients often "turn a corner" when using this practice.

Additionally, anxious or grief-stricken patients are also well served by walk and talk psychotherapy. "Because grief can be so totally consuming and feel so heavy, having the counterpoint of being outdoors and accomplishing something positive for one's health can provide a sense of aliveness."

She also says that relationship conflicts are where "light bulbs really go on in terms of having a different perspective. In an outdoor setting, [patients] are more receptive to feedback from the therapist."

Kendrick agrees. "Clients who are feeling trapped in a relationship or a job, or who are pretending to be somebody they are not will feel a sense of freedom" with walk and talk therapy." Hays adds that domestic abuse patients may also benefit by "being able to frame things more positively."

Cockrell has also found walk and talk to be especially good for his male patients.

"I have a theory that men have difficulty with eye contact in the office, chair to chair, knee to knee, revealing very private and possibly painful things," he tells WebMD. "Walking side-by-side can help a man become vulnerable."

In addition, he says substance abusers can benefit from walk and talk movement.

Walk and Talk Therapy: Confidentiality Concerns Back to top ↑

What happens if a client, wrestling with an explosive or emotional issue encounters someone they know -- perhaps a neighbor or work colleague -- during a walking psychotherapy session. Would confidentiality be compromised? How would that situation be handled to minimize embarrassment? What are the boundaries?

"Those are exactly the kinds of situations that are a therapist's responsibility to raise with the client," says Hays. "If one of us sees somebody we know, we just casually say 'hello' and keep on going. It's not explicit what's going on. In my experience it's been fine, not the slightest bit problematic."

Although it was of initial concern to Cockrell, he says, "It's just two people walking and talking; there is nothing to say this is a therapy session. If I see a group of people I recognize I can steer us in another direction. I've not had a client say it's uncomfortable."

Brooks-Fincher says occasionally she or her clients will be greeted by someone they know when in a public area. "It is something I discuss up front. It has been an interruption but not an impediment. We don't slow down and people realize we are in intense conversation."

Likewise, weather doesn't seem to be a deterrent to dedicated walk and talk patients and therapists.

"I walk with my patients 12 months a year," Cockrell says. "Once my clients have experienced walk and talk they don't want to go to the office. New Yorkers spend so much time indoors -- at home, in the office, in the subway -- it's a nice break. It's rarely so bad they can't put on an extra coat and gloves or carry an umbrella."

Finding a Therapist Who Offers Walk and Talk Therapy Back to top ↑

Although not new, a limited number of therapists offer walk and talk therapy. If yours doesn't, feel free to request it, say experts. None of the therapists WebMD spoke with charge a premium for a walk and talk therapy session over a traditional office session. Hays stresses that therapists don't need any special training to conduct walk and talk therapy, so if it appeals to you, bring up the possibility.

"I'm getting emails from across the country and across the world," says Cockrell of interest in the walk and talk movement. "It's highly appropriate for patients to take control of treatment and ask [a therapist] to think about adding this to his practice."

The therapists themselves also reap benefits from the practice of walk and talk therapy, which, in turn, benefits the client.

"This has been a very positive thing for me," says Cockrell. "I find it invigorating. The result is that I'm on my game and my patients feed off my energy. I'm very and focused, very goal-oriented, which is beneficial for them."

Adds Brooks-Fincher, "I think it keeps me fresh as a therapist to be doing something a little bit different."

"Sitting is passive, it's a deflated posture," says Cockrell. "Walking is literally moving ahead. People feel like they are moving forward in their issues. They can tackle things better and faster."

Patient Debbie agrees. "I have definitely seen a lot of change and growth in myself all for the positive. I also look forward to seeing [Cockrell]; the sessions are unconventional and there's a sense of embarrassment that I just don't feel now. I would definitely recommend it to others."

London Times Back to top ↑

Source Sunday Times

Mention the word “psychotherapy” and you probably imagine a couch, bookshelves full of Freud and Jung, and a therapist in a leather armchair. But what about a therapist in trainers, dispensing advice as he or she hikes around the local park with a client.

And yet this is what one New York therapist does, and it's a method that could have significant benefits here, say mental health experts. It is also a method with an impeccable pedigree: Sigmund Freud, the grandfather of the talking cure, pioneered it when he conducted a “walking analysis” of Max Eitingon, the physician, on their regular walks around the Ringstrasse Park in central Vienna.

A century on, and Clay Cockrell, 37, a social worker and psychologist, is running what he describes as a “dynamic”, cognitive behavioural therapy (CBT) practice from his office in downtown Manhattan. Having started a traditional, consulting room-based New York practice in 1997, he stumbled on the open-air approach by accident.

“Three years ago I was working with a Wall Street client who led an incredibly busy life and was having a difficult time getting off work in the middle of the day. So I said to him: ‘It's springtime, beautiful weather, I'll meet you.' We met near Battery Park and we walked. It was dynamic; he became more focused, more energetic, more hopeful. I started offering it to other clients, and it took off.” Now, he says, his entire practice - 40 clients a week, at $150 (£75) a session - is outdoors.

Cockrell sees most of these clients in Battery Park, Riverside Park or Central Park, and says that he has developed a “really good” inner clock. “The sessions last the standard 50 minutes, but I'm pretty good at timing my walk. I do have a wristwatch, but I try not to look at it as I think it's rude when a therapist looks at his watch. So I've developed a few paths and generally know how long they will take.”

However, there can be exceptions, especially when clients are upset and walk quickly, disrupting his timing. Sometimes the opposite happens. “When poignant things come up or if one of us wants to make a point, we will stop and sit on a bench. Take a moment before moving on,” he says. Cockrell claims that his approach works best with men. “They have a much more difficult time talking about intimate things than women. But when you're walking side by side, it's just two guys walking through the park. You don't have to sit and make this deep dark confession into the eyes of another human being.” The only downside, he says, is when poor weather forces a return to the consulting room, something all his clients are reluctant to do. “I try to avoid that wherever possible. It becomes a different dynamic; the rhythm of the conversation changes.”

A country-side stroll is a mood lifter Back to top ↑

Mind, the mental health charity, also agrees with the health benefits of being outdoors, stressing last year the need for “ecotherapy”, or “green” exercise. Its research indicated that 71 per cent of people suffering from depression reported a lifting of their mood after a walk through a park or the countryside, while 22 per cent felt their depression worsen after a stroll through an indoor shopping centre.

Clearly, Cockrell's approach is one that appears to suit solution-focused therapies such as CBT - where practitioners sometimes take clients outside the consulting room to confront their fears - than it does psychoanalytic therapies, with their insistence on privacy and quiet. These factors, says Brett Kahr, a British psychotherapist and author of Sex and The Psyche, are why he would not adopt such an approach.

“Because the kind of psychotherapy I practise is private, patients know that they can say anything and that it will never leave the room. And it's often in the room that stories of abuse, marital breakdown...whatever...can emerge. If I were to take patients on a walk, I would worry about confidentiality and about the intensity of concentration that you would lose.”

And yet Kahr adds that he once supervised a trainee psychotherapist who took a schizophrenic patient on weekly walks around Hampstead Heath. “They had some very touching conversations, so I'd like to remain open-minded.”

Going outside may be an avoidance tactic Back to top ↑

Phillip Hodson, a psychotherapist in London, also believes that “whatever works” is valid. “I often work with creative performers, for example, and if a concert pianist wants to get up and play the piano in my consulting room to illustrate something, am I going to tell him to stop? Of course not. I'm going to sit and listen.”

But he points out that a client's desire to move outside may be driven by wanting to avoid a difficult issue. “A client once asked if we could go for a walk, and I said no. What needed to be talked about outside that couldn't be talked about in the room?”

Diana Symonds, 34, a legal recruitment consultant, came to see Cockrell suffering from anxiety about a career change and “residual childhood issues”. She likes his approach as she doesn't have “to sit around in a dreary office on a couch with no padding, feeling like I'm sitting on the previous patient's dirty clothes. What's more, he offers concrete advice, which I like. I didn't want someone just to listen, I wanted help taking action.”

As for confidentiality, Symonds says that it's the norm in New York to talk about all topics out in the open. “Anyway, whenever we get too close to people, we go quiet while we move past them. I've never felt uncomfortable. Plus, I like the exercise.” Surely it's only a matter of time before we see therapists on the march across Hampstead Heath.

Jersey City Back to top ↑

A therapist without a couch, Local man does 'walk-and-talk' therapy in NYC parks

By Ricardo Kaulessar,

This article is another installment in an occasional series of articles "Odd- cupations" about Hudson County residents with unusual or interesting jobs.

Clay Cockrell is someone who answers the old question, "Can you walk the walk and talk the talk?'

Cockrell, who lives in Downtown Jersey City with his wife Sandy, is well known around town for his involvement with the acclaimed "J City Theater Company" that puts on stage productions in Hudson

Cockrell has also worked for over 15 years as a therapist in Manhattan, and is a Licensed Clinical Social Worker (LCSW).

But Cockrell does not conform to the stereotype of the therapist sitting on a chair listening to a client talk about his anxieties on a couch.

Instead, he is the founder of "Walk and Talk Therapy." In the past five years, he has seen hundreds of clients outdoors, and his sessions are conversations carried out in New York City parks and streets.

"The cool thing about doing this is, I have seen a lot of my clients get better a lot sooner," Cockrell said. "There is something about moving, which I think is a symbol for moving forward."

Therapy in action

Cockrell credits his wife with suggesting that he get out of the office and into the streets, after he told her about a client he was having difficulty helping.

"She said to me, 'You like being outdoors,' and convinced me to do a walking session," Cockrell said.

Cockrell began seeing results. Soon, he offered other clients his new walk-and-talk sessions.

"I started out with some clients who were more creative and out of the box, and then moved on to corporate clients," Cockrell said.

Cockrell's walking sessions run from $100 to $150 for 50 minutes, depending on the time of day.

He meets his clients at their office and then they make their way to Central Park if they are uptown, or Battery Park if downtown.

He sees six clients a day, three in the morning and three in the afternoon. Cockrell has curtailed his workload, saying he becomes "toast" after all the walking - and talking.

Seeing results

But Cockrell said this therapy has become beneficial for him in his work."My clients are only in therapy with me for one to two months, whereas before it was six months to a year before we saw results," Cockrell said. He continued, "After a couple of sessions, we start talking about other things, or they have moved on and don't need therapy anymore."The constant turnover has helped Cockrell's business, as he is starting a waiting list as result of the growing popularity of his unique practice. But being a therapist in action takes a toll on him."It takes a lot of me, as I have to get myself to the energy level of the person I am meeting has," Cockrell said. "That means working out in the morning every day; doing stretches between sessions and of course, having good shoes." When asked if he has gotten strange reactions on the street, he said there hasn't been "a lot of notoriety."

Walking and talking in JC

Cockrell said he would like to do a trial run (or walk) of his sessions in Jersey City or Hoboken sometime next year along the Hudson River. But he said he would have to work out his schedule to accommodate clients on both sides of the river since most of his 25 clients are based in Manhattan.Back to top ↑

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