What You Should Know About Walk and Talk Therapy and Other Non-Traditional Counseling Settings

Curt and Katie chat about non-traditional therapy settings like outdoor walk and talk therapy as well as home-based counseling. In the first of a two-part, continuing education podcourse series, we look at the basics, including why therapists should consider these settings (and may not), clinical and cultural considerations, and best practices.

Transcript

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In this continuing education podcast episode, we look at non-traditional therapy settings

For our third CE-worthy podcourse, we’re looking at the basics of bringing therapy into non-traditional settings, including walk and talk therapy and home visits. We cover a lot of topics in this episode:

What are non-traditional therapy settings?

• The focus of this episode is walk and talk and home-based therapy
• Client’s locations like home, school, or work; community-based settings
• Anything beyond the typical therapy office or telehealth settings are worthy of consideration
• Creativity and collaboration in creating the space
• How different the therapy can be when opening up more settings as possibilities

Why should therapists consider these non-traditional therapy settings?

• Logistical considerations that can lead to these settings being the ideal choice (or only choice)
• Clinical indications that walk and talk or home-based therapy is a better choice
• The impact on changing settings on the therapeutic relationship and the therapeutic work
• Specific modalities that are best served by client-centered spaces
• Assessment, treatment teaming
• How access, attendance, and attrition are impacted
• The therapeutic impact of the settings and movement

What are the hesitations therapists have in considering alternative settings for therapy?

• The challenges in creating systems and managing the logistics
• Lack of alignment with the medical model
• Lack of training and guidance
• Legal and Ethical considerations (that will be talked about in next week’s episode)

What are the clinical and cultural considerations when doing therapy outside or in someone’s home?

• Navigating the shifting relationship and boundaries
• Cultural differences between therapist and client, and assumptions made about the relationship
• The importance of leading the conversation about these relationships
• Hospitality and others who may be present at a client’s home
• The unusual space, the level of confidentiality, and emotional containment and depth of conversation
• Treatment planning based on where you meet and how the client interacts with the space
• The importance of the clinician holding the therapeutic space and attention
• Creating the space and the contract for how therapy will happen
• Cultural norms for the activities and for the client and family – more complexity to discuss

Clinical How-To for Non-traditional Settings

• Assessment considerations
• Client and clinician characteristics
• Alignment with treatment goals and presenting concerns
• Presenting issues can vary and assessment can be important
• Initial assessment appointments and making the decision early in treatment
• Treatment Formulation related to active versus passive interaction with the space
• The importance of true informed consent and the dynamic nature of process contracting
• Introducing predictability
• Risk assessment
• Knowing your scope and what types of professionals you might consider consulting

Our Generous Sponsors for this episode of the Modern Therapist’s Survival Guide:

Dr. Tequilla Hill

The practice of psychotherapy is unique, creative, and multifaceted. However, combining a more demanding schedule and handling our own pandemic related stresses can give rise to experiencing compassion, fatigue, and the dreaded burnout. Unfortunately, many therapists struggle silently with prioritizing their own wellness across their professional journey.

If you are tired of going in and out of the burnout cycle and you desire to optimize your wellness, Dr. Tequilla Hill a mindful entrepreneur, yoga, and somatic meditation teacher has curated How to Stay Well While You Work Therapist Wellness Guide to support providers that are struggling to manage your own self care.  Subscribe to Dr. Hill’s Stay Well While You Work! Therapist Wellness Guide and you can find many of the inspiring offerings from Dr. Hill’s 17 years as a practice leader, supervisor, mentor, human systems consultant and wellness enthusiast.

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If you love our content and would like to bring the conversations deeper, please support us on our Patreon. For as little as $2 per month we’re able to bring you more content, exclusive offerings, and more opportunities to engage in our growing modern therapist community. These contributions help us to expand our offerings for continuing education events and a whole lot more. If you don’t think you can make a monthly contribution – no worries – we also have a buy me a coffee profile for one-time donations support us at whatever level you can today it really helps us out. You can find us at patreon.com/mtsgpodcast or buymeacoffee.com/moderntherapist. Thanks everyone.

Receive Continuing Education for this Episode of the Modern Therapist’s Survival Guide

Hey modern therapists, we’re so excited to offer the opportunity for 1 unit of continuing education for this podcast episode – Therapy Reimagined is bringing you the Modern Therapist Learning Community!

Once you’ve listened to this episode, to get CE credit you just need to go to moderntherapistcommunity.com/podcourse, register for your free profile, purchase this course, pass the post-test, and complete the evaluation! Once that’s all completed – you’ll get a CE certificate in your profile or you can download it for your records. For our current list of CE approvals, check out moderntherapistcommunity.com.

You can find this full course (including handouts and resources) here: Walk &Talk and Other Non-Traditional Therapy Settings

Continuing Education Approvals:

When we are airing this podcast episode, we have the following CE approval. Please check back as we add other approval bodies: Continuing Education Information

CAMFT CEPA: Therapy Reimagined is approved by the California Association of Marriage and Family Therapists to sponsor continuing education for LMFTs, LPCCs, LCSWs, and LEPs (CAMFT CEPA provider #132270). Therapy Reimagined maintains responsibility for this program and its content. Courses meet the qualifications for the listed hours of continuing education credit for LMFTs, LCSWs, LPCCs, and/or LEPs as required by the California Board of Behavioral Sciences. We are working on additional provider approvals, but solely are able to provide CAMFT CEs at this time. Please check with your licensing body to ensure that they will accept this as an equivalent learning credit.

Resources for Modern Therapists mentioned in this Podcast Episode:

We’ve pulled together resources mentioned in this episode and put together some handy-dandy links. Please note that some of the links below may be affiliate links, so if you purchase after clicking below, we may get a little bit of cash in our pockets. We thank you in advance!

Cooley, S.J., Jones, C.R., Kurtz, A., & Robertson, N. (2020). ‘Into the Wild’: A meta-synthesis of talking therapy in natural outdoor spaces. Clinical Psychology Review, 77, 101841. ISSN 0272-7358, https://doi.org/10.1016/j.cpr.2020.101841.

Donachy, G.S. (2020). Psychotherapy outside the consulting room: ending therapy during the global pandemic, Journal of Child Psychotherapy, 46:3, 373-379, DOI: 10.1080/0075417X.2021.1903065

For the full references list, please see the course on our learning platform.

Relevant Episodes of MTSG Podcast:

Dual Relationships: Pros and Cons

Post Pandemic Practice

What Clients Want

Shared Traumatic Experiences

The Balance Between Boundaries and Humanity (an interview with Dr. Jamie Marich)

Who we are:

Curt Widhalm, LMFT

Curt Widhalm is in private practice in the Los Angeles area. He is a member of the California Association of Marriage and Family Therapists ethics committee, an Adjunct Professor at Pepperdine University, lecturer in Counseling Laws and Ethics at California State University Northridge, a former Law & Ethics Subject Matter Expert for the California Board of Behavioral Sciences, and former CFO of CAMFT. Learn more at: http://www.curtwidhalm.com

Katie Vernoy, LMFT

Katie Vernoy is a Licensed Marriage and Family Therapist, with a Master’s degree in Clinical Psychology from California State University, Fullerton and a Bachelor’s Degree in Psychology and Theater from Occidental College in Los Angeles, California. Katie has always loved leadership and began stepping into management positions soon after gaining her license in 2005. Katie’s experience spans many leadership and management roles in the mental health field: program coordinator, director, clinical supervisor, hiring manager, recruiter, and former President of the California Association of Marriage and Family Therapists. Now in business for herself, Katie provides therapy, consultation, or business strategy to support leaders, visionaries, and helping professionals in pursuing their mission to help others. Learn more at: http://www.katievernoy.com

A Quick Note:

Our opinions are our own. We are only speaking for ourselves – except when we speak for each other, or over each other. We’re working on it.

Our guests are also only speaking for themselves and have their own opinions. We aren’t trying to take their voice, and no one speaks for us either. Mostly because they don’t want to, but hey.

Stay in Touch with Curt, Katie, and the whole Therapy Reimagined #TherapyMovement:

http://www.mtsgpodcast.com

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Consultation services with Curt Widhalm or Katie Vernoy:

The Fifty-Minute Hour

Connect with the Modern Therapist Community:

Our Facebook Group – The Modern Therapists Group

 

Modern Therapist’s Survival Guide Creative Credits:

Voice Over by DW McCann https://www.facebook.com/McCannDW/

Music by Crystal Grooms Mangano http://www.crystalmangano.com/

Transcript for this episode of the Modern Therapist’s Survival Guide podcast (Autogenerated):

Curt Widhalm  00:00

This episode of The Modern Therapist Survival Guide is brought to you by Dr. Tequilla Hill.

Katie Vernoy  00:05

The practice of psychotherapy is unique, creative and multifaceted. However, combining a more demanding schedule and handling our own pandemic related stresses can give rise to experiencing compassion, fatigue, and the dreaded burnout. Unfortunately, many therapists struggle silently with prioritizing their own wellness across their professional journey.

Curt Widhalm  00:26

Dr. Tequilla Hill a mindful entrepreneur, yoga and somatic meditation teacher has curated How to Stay Well While You Work! Therapist Wellness Guide to support providers that are struggling to manage your own self care. Stay tuned at the end of the episode to learn more.

Announcer  00:40

You’re listening to The Modern Therapist Survival Guide where therapists live, breathe and practice as human beings. To support you as a whole person and a therapist, here are your hosts, Curt Widhalm and Katie Vernoy.

Curt Widhalm  00:56

Hey, modern therapists, we’re so excited to offer the opportunity for one unit of continuing education for this podcast episode. Once you’ve listened to this episode, to get CE credit, you just need to go to moderntherapistcommunity.com, register for your free profile, purchased this course pass the post test and complete the evaluation. Once that’s all completed, you’ll get a CE certificate in your profile, where you can download it for your records. For a current list of our CE approvals, check out moderntherapistcommunity.com

Katie Vernoy  01:28

Once again, hop over to moderntherapistcommunity.com. For one CE once you’ve listened.  Woo hoo!

Curt Widhalm  01:35

Welcome back modern therapists. This is The Modern Therapist Survival Guide. I’m Curt Widhalm with Katie Vernoy and this is one of our continuing education eligible episodes. Today we are doing a dive into therapy in non traditional settings.

Katie Vernoy  01:55

So when we were thinking about doing a continuing education podcast episode, one of the things that I was thinking about are the types of questions that I get a lot. And the topic for today is non traditional therapy settings. This is something I’ve done for most of my career, I worked in milieu settings. I’ve done walk and talk therapy. I’ve done playing at a playground and a school therapy, I’ve done home visits. And so I wanted to make sure in this first episode that we have the foundational knowledge of what it is. So I get a lot of basic questions about what do you do? How do you do it? What are the logistics? And then I also think there are folks who just aren’t going to consider it because they don’t know why to do it, and what benefit it has. And so for folks who are listening, we have two episodes this week is a basic 101, what are these non traditional settings? How do you do them? What are some best practices? Beginning level course. And then next week, Curt and I are going to really dig into the ethics and nuance. But we wanted to make sure you had the basics before we dug into it further. For folks who’ve been doing it and aren’t sure they’re doing it right. This is a great reminder of like, these are the things to consider. And these are some of the logistics that might go into place and making this a clinically appropriate service for your clients. Even before the pandemic hit many different types of therapeutic programs are happening outside of the office. I know we’ve all heard about kind of like the adventure camps and different things for folks. You know, oftentimes kids, troubled teens, there was a lot of different things going on. I mean, I in researching this, I found a lot of folks doing walk and talk therapy. Certainly when I was coming up in community mental health, we were doing home based therapy. But I think because of the pandemic, I think it gave a lot of us an idea of like, wait a second, if I don’t want to keep my office and/or if I want to be outdoors and not inside with someone, what are my options for therapy if someone just can’t handle the screen of telehealth? And so I think it’s it’s something where, to me, I’ve started doing this, I thought it was really exciting. And I wanted to share with everyone kind of I’ve get lots of questions about how do you do this stuff. And so I figured, why not do a deep dive on it.

Curt Widhalm  04:12

We’re actually going to make this part one of a two part series here. This first episode is going to focus more on the hows and the whats of doing. Our second episode is going to dive into some of the legal and ethical considerations. You’ll get a flavor of that in this episode. But this is really more of the hows of going about this. So Katie, first let’s start with talking about like, what kind of therapy settings are we talking about here?

Katie Vernoy  04:46

I think the primary thing we’re going to talk about in the episode will be home based and walk and talk but I want to reiterate that there is so much flexibility on where we can do therapy and so some of the types of settings that you might want to be considering and kind of extrapolating out to, could be home/school/work. So kind of the clients locations, outdoor therapy can be walk and talk, but it can also be like groups and and retreats and different things. I mean that that’s probably a little bit beyond the scope of this. But I’ve gone to medical facilities, I’ve gone to social services buildings with folks, wellness centers, out in the community, when there’s just not a great place to meet, you can meet at a restaurant or a library or a church or a YMCA. I’ve actually done therapy with folks in the car on the way somewhere. And when I was working in substance abuse treatment, this is something that’s been around for a long time, too. There’s kind of the milieu setting, but there’s also like camping and other things. And so there’s, there’s a lot of times when therapy can be happening and a lot of places where therapy can be happening. But it has a lot of things to consider, especially within relationship and confidentiality. But we’ll dig deeper into that.

Curt Widhalm  06:03

I’m hearing this just from the get go as not in the traditional office setting, basically anything else goes and it speaks to just that so much of what we’re allowed to assume can happen is in the nature of a four walled sort of office someplace. And that’s the reason to look at that even with many of our listeners, possibly having done non traditional therapy, during the course of the COVID 19 pandemic, that there might be some considerations in here or to be able to evaluate some of the effectiveness of how we’re going about that. So this isn’t just going out and doing what we’ve been doing in the office outside, though, it’s not like, you know, I’m not doing EMDR and just waving my hand in front of somebody while they’re walking.

Katie Vernoy  07:00

I think that would be tough. That would require a lot of coordination. I think it really varies. But I think, and we’ll go into a lot of this more in depth, but I want to get a kind of a higher level overview. I think it always is important to start with kind of a collaborative assessment of appropriateness. And so it’s a conversation you have with your client, you want to make sure that you’re doing all of these things. We’ll talk about that later. And then once you’ve decided, yep, this is for my client, or the client says, “Yep, this is for me,” you meet wherever the designated place is that are, which could involve logistics and timing, it could be two people meeting in a single place. I mean, there’s some stuff there that can be interesting. You could meet in a place and you could kind of passively engage with it, meaning I’m doing regular therapy, but it’s outside or I’m doing regular therapy, but it’s at the client’s home, or you could engage with a space, you know, you’re interacting with nature, you’re interacting with the family or setting something up at their home. There’s also a huge shift in the treatment relationship and so there’s, and again, this is high level, we’ll go into this in more detail. But there’s more of an equality there, because you’re experiencing something together, potentially even there’s a shift in the power dynamic. If you’re going into their home, you want, there’s always going to be the planning for confidentiality, which if you’ve got your little office and your noise machine, like you’re pretty clear that you’re keeping confidentiality. And then there’s also the environment, which could be very uncertain. I think that for some folks, they have a modality that they do. And so some people are just home based, or some just do walk and talk, I find I’ve not added homebase to my current practice. But I find having a flexibility there can be interesting, but then it could be that you’re like, navigating with the client, are we meeting at the park today, are we going to be on video or we’re going to be in my office. And so there can be some systems and different things in your business practice that you want to consider. It’s an interesting type of therapy, because there’s a lot of possibilities. But there’s a lot of uncertainty that can come into play, because it’s not an environment that you’ve carefully curated with all of your professional certifications and your comfy chair, or it’s not that video setting that you’ve potentially done the same and then the client has created their own space too. So it’s it’s a different type of treatment.

Curt Widhalm  09:19

I’ve done some of this kind of work mostly back when I was pre licensed and newly licensed and part of it was the agency job that I had. But one of the things that you’re talking about that brought back some memories is just the client approach to therapy can be a lot different when you’re coming into their space than it is with them coming in. I noticed that my clients were a lot more cooperative when they started coming to my office. There was almost kind of like, alright, I’m buying into needing to be in the space. But some of those clinical factors that come up, some of what might be called defenses, would maybe show up when therapist is coming into their space. I’m guessing these are some of the things that we’re going to be talking about as far as just kind of the hesitations that we have of approaching therapy in a different way. And also just kind of needing some interventions or conceptualization differences when we do approach therapy in this way.

Katie Vernoy  10:21

Of course, yeah.

Curt Widhalm  10:22

Before we get into that stuff, though, why might we be put into this situation in the first place? Why? What are some of the either client or world factors that might be reasons that we need to see clients outside of our traditional offices?

Katie Vernoy  10:39

Well, I think the reason that a lot of folks potentially are revisiting these thoughts are because the office doesn’t work and in person is needed. And so for me, sometimes it’s been lack of efficacy with telehealth or privacy, it could be just kind of needing to get your eyes on a client and not feeling comfortable in an in office setting. Maybe you don’t even have an office anymore. A lot of people gave up their office and so having this possibility of either meeting them at their home or in a public space can be really helpful. I think the other thing, and this is something where you say like, why would we be in this situation, it actually can be a situation where a client is not comfortable with telehealth and not comfortable being in an enclosed space for an hour, because of COVID or because it’s feels too constraining or the eye contact is too weird. And so like walk and talk can be actually a better option for them. With home based, sometimes there’s this, you know, sometimes it can be mobility and transportation issues, it could be like, my client can’t leave their house, I need to get my eyes on them, I’m going to go out there. But sometimes it can be a clinical issue, where being in the home makes sense, you get to see their full, you get a full assessment of their environment, how they interact with their environment. I know when I was working in community mental health work, there was this notion of like, if you’re providing interventions, that requires two or three rooms, and they actually only have one, you know, like set up a homework station or whatever. Like, there’s a lot that you don’t know, especially if your clients aren’t telling you when they come into your office, or even they don’t show you on your on your screen, right. They’re just in this little curated space, maybe with a a filter in the back. And so I think oftentimes it can be a client choice because of what the other options are, as well as a clinician choice. It also shakes things up. And so it can, it can decrease the stuckness that you’re feeling or they’re feeling in their treatment. There’s a hesitance, and we’ll go into hesitations a little bit more, but there’s a hesitance to break out of kind of that expert cocoon, but it can decrease formality and distance and it can make things less curated and professional. So it it shifts the relationship and then for a lot of folks that can be very positive, and it may be more aligned with a theoretical orientation.

Curt Widhalm  13:04

I’m also imagining some of the client considerations that might come up, might end up being a more effective way of bringing some interventions to life and thinking of things like exposure and response prevention, OCD, or even potentially working with clients with eating disorders, who might need more clinical support in environments where it’s either making food or generalizing some of the food related issues into eating out and other examples like that.

Katie Vernoy  13:38

Absolutely, I think it’s something where there are different benefits, obviously, to the different math methods. But sometimes it is an obvious clinical choice, if you open up your mind to I could be with my client in another space, I can be with them at their home, I can be with them in a public space. I mean, like talk about specific phobias of bugs, I mean, like, you can actually be with them in these spaces, you know, there were clients with social phobia, that you go to the home and you slowly move them back to the office or slowly get them to the office and and help them with those things. So I think it’s really something where being very, very, very thoughtful can be helpful. But I did do a little bit of research, and I’ll share some of that with you for the two specific environments that we’re talking about. Because I think it’s helpful to recognize some, some efficacy that goes beyond like, oh, well, we could do ERP together in the right setting. Right? So with the home environment, like I said, you can do a better assessment of them in their environment, but you can also recruit community members to support the client and treatment if it’s appropriate. So you can have family, you can have the school or a treatment team, you can you can pull folks in who are more likely to attend in that space than making the trek to your office, because they might just be there. Or it might be more of a comfortable setting. It increases access and attendance. It also can decrease attrition. So there were there were a study done with children and and vets where the efficacy of telehealth and in home in person were pretty similar. But people who had in home therapy were more likely to complete the treatment they were they stayed in it longer. And so there was a higher level of efficacy there. For homebound clients that are homebound for medical reasons, you can actually get treatment to them. And then you can also when you use this for crisis management, and you’re coming to someone’s home, you can do I think, obviously, better safety planning, and all of those things, but it actually decreased hospitalizations. On the walk and talk side that was really interesting. There, I was looking at a lot of different articles. And one of my favorite articles was Coaching Whilst Walking In Nature or something. And there was a lot of these use of the word ‘whilst’ which really made me very excited.

Curt Widhalm  16:07

Very British. Oh, yeah.

Katie Vernoy  16:08

Very British. So when you walk and talk, whilst outdoors, the setting itself was seen to be very, very beneficial. Just being outdoors being in nature. And some studies showed this as the most beneficial element that people identified was just being outside, kind of being in nature. And so that, in and of itself has a clinical benefit, just going outside doing nothing else just going outside. And some people actually would like, walk out of their office and just sit outside like, that was their outdoor therapy. And that showed benefit. If you also do kind of the physical activity, there’s going to be more blood to the brain, there’s better processing, and even though walking side by side, I’m sure as an EMDR person, you understand the bilateral movement here? But they were saying that experiential processing is also enhanced while doing that activity: increased creativity, learning and memory, I mean, all these things are amazing, right? You might have new insights, or even like the physical release and being more embodied, because you’re actually moving while you’re talking and doing those things. I think the other thing is, I don’t walk the whole time. But during the time that you’re walking, you don’t have eye contact, you’re still connected. And there’s there’s some downsides to that. But there’s also this, it’s less intense. And there’s a different energy in that, that I think some clients find more beneficial. I think that the the biggest piece that is really for both of these, but especially in walk and talk is that you… you’re really… there’s a different way you’re relating to each other. When we’re sitting together and either we see on the screen just a little bit of space, or we just kind of walk into a room and sit down. There’s there’s information we don’t get. And so when you walk together, there’s just a whole different level of relational embodiment, that happens in the relationship. And I think for some clients, the the lack of formality, especially in the outdoor setting can be very helpful. So those are the reasons why to do it. But there are some hesitations. But I’m curious, before I jump into my list, what hesitations do you have, in thinking about doing these types of therapies, or these types of settings.

Curt Widhalm  18:26

I can come up with a number of them, but I know that we’re going to address a lot of them in the law and ethics part two part of this conversation. But some of the concerns that are going to come up is just like, how do you manage, like getting all of this stuff set up? That whether it’s client or therapist familiarity to just kind of the way things always have been. But clinically, I’m also having some concerns of like, if it just ends up becoming being in an environment that’s too distracting, and clients don’t end up retaining the information that actually gets talked about because they’re more focused on walking.

Katie Vernoy  19:11

And that’s fair. And I think that’s part of the assessment. I think, the the logistical pieces, we’ll talk about that next time. But I think there are a lot of logistics that may seem daunting, that actually aren’t that daunting, especially if you’ve got good systems to start out with. But a lot of folks are really hesitant because it’s not aligned with the medical model. And so this really pulls away from that, you know? If I’m telling the psychiatrist or medical doctor, “Yeah, I’m meeting my client in the park,” depending on their perspective, they may lose respect for me and the work that I’m doing, right? There’s not a lot of research, I think that’s changing but the lack of training and guidance can be pretty daunting for folks because it’s like, well, how do I get myself to a place that I’m doing this right? And of course, you know, confidentiality, dual relationships, informed consent… to be continued in the next episode. But I think that there’s a lot of hesitations around it. But I think if you address them clinically, you know, some of the stuff you’re talking about, I think it can be pretty effective. It’s not effective for everyone. And I think there’s different settings that are better for different folks. But I think that’s the reason to make sure that you truly understand what you’re doing so that you can get a handle on that.

Curt Widhalm  20:28

And, you know, if we can segue here for a quick moment is that, well, a lot of what we get taught ends up being in that traditional therapeutic talk space. I don’t think any of us are actually inventing, doing walk and talk therapy, this has been around in some environment or another that while it might not be the most, you know, clinical trials, you know, replicated sort of things, there’s plenty of qualitative studies that indicate what makes these things successful.

Katie Vernoy  21:00

Yeah, and I’ll put links to some of the stuff that I found in the show notes. I think there’s more and more lately, especially with the pandemic, especially for walk and talk because of people transitioning outdoors, and there’s all kinds of positive kind of tales of how effective this is. And yet, I think that there are some clinical and cultural considerations to keep in mind, because I think as I was reading, I was getting super excited, I’m like, “Okay, I’m gonna do more of this, this is gonna be amazing!” And then I, you know, then you calm down and think about, you know, but it’s not really right for every client. And there are things to think about.

Curt Widhalm  21:40

So what might be some of those considerations of who would be a good candidate for it? Or who might not be a good candidate for it?

Katie Vernoy  21:51

Well, there’s, there’s a few different times I’ll address that because I think that’s a really good question. I think the first one is, you want to make sure you have a client that can navigate the shift in the relationship, I think there are clients who may become, I don’t know if confused is the right word, but they might, they might have a challenge in really being able to navigate the shift to a more informal relationship. There’s a lot of boundaries that could be crossed. I think about when you’re outside, for example, like you’re going to be wearing different clothes, most likely, so that are appropriate to get dirty in or appropriate to sweat in or walk, like wearing tennis shoes. So even in kind of how you’re showing up, that would be very interesting. I mean, there’s, there’s the whole hospitality, if you’re going to a client’s home, and they become the host to you, or their parents do, or, or they don’t, and you’re kind of stuck trying to navigate a home environment that isn’t yours. And so with those, all of those boundaries, I think the client has to be able to hang with that. And the clinician does, too. I think I was reading somewhere that clinicians or a clinician, it was one of those qualitative studies was talking about how they felt this impulse to become a friend of the person they were hanging out with. And so it’s something where as a clinician, and we’ll definitely go into this in the law and ethics portion of this, but those strong boundaries, and that professional persona that can kind of be in every setting. And I think that’s the thing that maybe this is important, too, for a little bit of a side note.. But what I learned a lot of in my community mental health was really strong professional boundaries and professional presence in every setting, while still being personal, still showing up as myself, you know, whether I was camping, or whether I was walking with someone or playing basketball out on the court outside and at their school, like, I would show up as a professional while still being me and personal. And I think there may be another podcast episode on just how to do that. I think we actually did talk about some of that at some point. So I’ll look through and we can put some of those other episodes in the show notes. But the boundaries are so dynamic and fluid, that it becomes very different to manage than just coming into your office and sitting down or popping onto a screen. I think another thing that it was very stark for me in public mental health, but maybe stark for others in different settings, is that there’s there’s potentially very strong cultural differences between you and the person that you’re showing up at their house or you’re walking in public. And so I think being able to navigate what is it going to look like if the two of us are walking around outside? Or what is it going to look like if I show up to your house every week? Like what are what are the assumptions going to be made? What impact is that going to have on you? And we’ll talk about the confidentiality elements of that on the next episode, but the clinical and interpersonal or kind of therapeutic relationship elements of that, it becomes more obvious the cultural differences, potentially even socio economic differences that show up when you’re experiencing things together.

Curt Widhalm  25:22

Tell me more about that because I didn’t work in community mental health and B: when I was doing this kind of work, it was more local to neighborhoods that I was already in. So maybe some of those cultural differences weren’t quite as apparent in the way that this showed up.

Katie Vernoy  25:40

Well, I think about clients who are racially or ethnically different from me, or very different ages, so if I have an older person walking with me, who is ethnically different from me, are there assumptions that are being made? If I’m a, you know, a white person in formal attire, in a nice car coming into a neighborhood that typically is, you know, below the poverty line? And there’s a lot going on, am I… do they assume that I’m a social worker, or caseworker of some sort? You know, more like, are they getting in trouble? You know, I think there’s can be assumptions made and and I’ve even thought about with certain clients, like, I hope that there is an acceptance and an inclusion and everybody can be seen together and all those things, but people are more and less likely to be seen together. And there was a situation where a client of mine, a black woman, and I were walking, and someone came up to us and talked about how beautiful it was that the two people together, friends, you know, and the assumption, I’m glad the assumption was not that I was her social worker or her therapist. But it was interesting, because it certainly brought the conversation of race into that session, as we moved along, away from that person to talk about, like, what does it mean that there are the two of us here? And how do we feel about what he said, and, and so it definitely is something where any differences really show up. And it becomes, unless you try to avoid it, it becomes clinical fodder, which I think can be very helpful.

Curt Widhalm  27:25

I guess that’s something that I didn’t really experience in my work, because for a lot of the community outings that I was doing, it didn’t seem like it was necessarily a therapist, it was maybe more observable as being a, I don’t know, a babysitter or something like that, because of working with kids, or, you know, just being somebody who’s out, you know, on a basketball court or a playground with somebody. Yeah, I’m sure that these days, if I was to do the same thing, it might look more like a dad or… But what I am hearing from you is lead some of the conversation or at least open that up to make it clinically relevant to help deepen what the therapeutic goals might be.

Katie Vernoy  28:14

Well, I think, sure, deepen the therapeutic goals, but I think it truly is, is really address the relationship. Because to me, if you don’t, a client may feel uncomfortable saying, like, I don’t want to be seen in public with you, or I don’t want you coming to my house. And so I think having that, that openness and directness, and this is what like, this is what it’ll look like and this is how our relationship may change. The client can opt into that. I know, there’s other things besides the relationship, but let me see if there’s any other points that I want to make on that. I think the other clinical consideration around the relationship, I think, is truly how you navigate. I mean, maybe it’s the hospitality. But it’s, but it’s, it’s whether it’s hospitality, and like they want to offer you food and drink or, you know, they want to, to invite someone else and introduce you to someone or those kinds of things, or if there’s a potential for kind of an advocacy and a dual role, where you’re all of a sudden, you know, kind of standing up for them…in a situation, I guess, this goes into more like family therapy, but like with a with a family member that pops in or whatever or or how you navigate if someone comes up. So I mean, I think there’s the relationship becomes more fluid and you’re more experiencing things together on an even level. And you have to make sure that your client can roll with that. Because if they can’t, if they’re a little bit more rigid, or if they’ll be confused by where the boundaries actually lie, it could be something that you have to kind of manage clinically ahead of time before you even consider these types of settings.

Curt Widhalm  29:57

This also seems to be another place where some of those cultural differences would come in, because, you know, in many cultures, just kind of that host role is going to end up really being something that, well, we might have kind of our traditional therapists kind of, you know, needing to evaluate every little thing. That might mean that we need to be more accepting or need to be more open to some of the different things that are unexpected. It’s like being able to kind of roll with the punches here a little bit.

Katie Vernoy  30:35

Oh, absolutely. I mean, I think if therapists can’t roll with the punches, they probably shouldn’t consider these types of therapies. Because if you’re in someone’s home, unless it’s a gigantic home with a specific space dedicated for your therapy treatment, you know, people might barge in, there might be phones ringing, there might be pets, I mean, there’s, there’s a lot of stuff that could be happening. But in an outdoor space, unless it’s a private space that only you own, you’re gonna be interacting with other folks. And there’s, there’s a lot of things that can come up. I mean, that segues nicely into the next kind of consideration that I put down here, which was kind of the unusual space. I mean, to me, this is a big one, you know, I think navigating the relationship, I think you and I both are fairly informal, I think a lot of our ‘modern therapists’ are more authentic with their clients. So this is not, that’s not a big stretch. But navigating this space. My goodness. That is a tough one, I think, sure, there’s confidentiality issues. And we’ll talk about those in depth as far as how you cover the base there. But the depth of conversation is actually a consideration. If it’s a very private outdoor space, maybe someone can really kind of maneuver into deeper conversations. But in some ways, it may be more of a practical conversation, it may be more of a coping skills conversation, at times, it could be a little bit more cerebral, and, and my style is a bit more cerebral, so it works for me. But in an article I was reading, and it was a case study, it was talking about how when he moved his client into an outdoor space, she was actually more emotionally contained and able to engage with a treatment more versus kind of this uncontained emotion of either being in his office or being on the phone in her own home. And so the, the moderating effect of the environment is one that is really important to consider, because, especially if you’re going to use more than one environment, because you can have a more contained conversation out in public, you might have someone completely boundaryless in their own home, because it’s my own home, and they’re laying around and doing what they do normally in their own home. And then in your office, it’s your setting. And so they may show up and be like you said, a little bit more compliant, a little more bought in. And so to me being able to figure out how is this client going to respond to this setting. And that may be something you don’t know until you actually go there. And then how it’s going to impact the types of conversation, the types of emotional reactions, regulation, you know, all of those different things like the level of emotional containment, I think, is really important to consider.

Curt Widhalm  33:32

And I think once again, you’re gonna see where diagnostics probably are a consideration as far as the kinds of material that you end up talking about out there. That, you know, well, being more contained with something like anxiety and being able to operate out in the environment in a way that’s, you know, self edited in case somebody sees what’s happening. That’s quite a bit different than working on deep childhood trauma.

Katie Vernoy  34:03

Of course. And I think it’s something where, as part of the treatment planning, for some of my clients, I’ve talked about going back and forth to the office or telehealth based on what we’re working on. And I think that there are also some folks who are actually more likely to dig deeper outside, because we’re walking and it’s just two people walking, you know, we’re keep moving, and they’re more comfortable, and there’s more of a free flow. And so it can almost even be client by client, sometimes. The most important thing about being outside or being in another space that’s not your own clinical curated space, is that you have to be able to hold the clinical space while facing the uncertainty of the experience. Like that is your job.

Curt Widhalm  34:54

Tell me more about what kind of risks that that brings up?

Katie Vernoy  34:59

Well, it is something where it’s kind of like you becoming your own transitional object. And I just made that up. So, so bear with me if it sounds ridiculous, but when your client is with you and you’re outdoors, the space that you’re holding is really more emotional, because you’re walking. So it’s, it could be the distance that you’re apart from each other, it could be, I actually walked slower with some clients, so that they don’t speed through and are out of breath and distracted by the walking. And so I moderate the pace a little bit. In a home setting, it could be identifying with the client, how you’re going to hold that space together. But you have to remain present, while walking, while interacting with pets if they’re not locked up, while paying attention to birds flying by or planes flying by. But like you have to stay present and keep the setting in place. Because if you’re distracted, or you’re too worried about walking, or whatever, you’re not holding the clinical space.

Curt Widhalm  36:06

How could you see someone not doing this well, like and what the potential impacts that that might have on therapy going forward?

Katie Vernoy  36:16

I think if people are really distracted, and in truth, when I first started walk and talk therapy, we were wearing masks and walking. And so it can be hard to hear. Being in a home and being in a setting where there’s constantly noise or someone coming in and there’s constant distractions, it’s equivalent to having therapy on Zoom, with a really bad internet connection… I know a lot of people can can relate to that. But it’s this thing where you have to keep coming back and keep coming back. Which is weird, because when you’re in a space together, there’s more verbal fluency, you’re not waiting for the connection to pick up. And there’s also a lot of physical interaction that you’re having, as far as you can see their nonverbals. And so if you’re really really distracted and worried about how you’re stepping or those kinds of things, the the ability to miss the really important things is very high. Or to be too impacted by the environment. So you know, there’s some loud noise that happens, you both interact with it. And if it’s not, like, hey, they were their anxiety shot up, and blah, blah, and it’s clinical, but like being completely distracted, kids are playing at the park, it triggers them, and you keep watching the kids and you’re not really actually processing what the trigger is, you’re just enjoying the kids, you know, playing. You know, I think it’s something that could be harmful if you’re not paying attention to what’s actually in the environment, how we’re interacting with it. And what I need to bring up.

Curt Widhalm  37:53

In doing this, it’s having a plan, it’s kind of being able to plan ahead, it’s not just kind of assuming that what’s happening in the office is going to magically happen, just while you’re in motion out in the neighborhood. It’s probably for the therapist having you know, an experience, you know, of what your walking path might be, and knowing kind of where, okay, this is the hot spot where all of the walking moms in the neighborhood get together and chit chat. And that might be a time where we kind of need to veer away for a little bit or, you know, this is where, you know, anything else happens along the way, the one really obnoxious, barking dog,you know.

Katie Vernoy  38:38

And I think the point that you just made is a really important one. If you are the person that are setting the environment, so like I picked a park by my office, you want to walk the route, you want to make sure you’re aware of the things and it could be different at different times. And sometimes you can’t predict all the variables you can’t do… you can’t account for everything that’s going to happen. You know, sometimes there’s going to be a baseball game in the middle of the day, and you had no idea. And so you’re there’s a lot more people than normal. But, but in environments that you don’t know, like a client’s home, when you go the first time, the client is really setting the pace, you know, and that’s part of informed consent that we can talk about, but like, what is it going to look like? Do we have a space? Am I going to get to your home and we’re going to take off and go somewhere else? You know, like what does it look like? But if you can do whatever you can to create a sense of predictability, and that’s one of the steps we’ll talk about later, I think the more you know about the environment, the more you know about the potential risks and uncertainties, the better you’re going to be able to navigate and hold that space for the client.

Curt Widhalm  39:46

Is there cultural considerations to consider out in what we’re calling the unusual space here?

Katie Vernoy  39:53

The first thing is identifying the cultural norms within a client’s home for example, or how they interact in public. I think there’s having those conversations around how you want to show up, and it could be even, and without requiring too much education from the client, but requiring it, you know, asking, is there anything I need to be aware of in coming to your home? You know, are there safety concerns? That’s, you know, that’s a separate topic. But are there other things that would be helpful for you and your family if I either did or didn’t do. One of the articles I read talked about taking off your shoes in a Japanese home or, or other types of things that you may want to consider, even attire, what is going to be appropriate for the activity, but what’s also going to be respectful to the family? Like if you show up in, like, a full sweat suit, is that going to be seen as appropriate to the family? Because they know you’re going to go out in the backyard and play basketball with the client, or is it going to be seen as disrespectful and unprofessional? And so I think there’s looking at how you navigate the relationship with the client, as well as any cultural factors specific to the family or the client, it really comes down to conversation. But I think it’s also just finding your own way of showing up that feels like it can kind of go across those things. You know, I think always entering with curiosity and humility, I think can always be very helpful, asking for clarification, if needed. But I think, as I mentioned before, I think within the relationship or even within the space, you want to make sure that you’re really paying attention to how you show up, and how you show up in relationship with the client.

Curt Widhalm  41:37

So I’m imagining that for these kinds of considerations, if you’re seeing multiple clients in a row, and do you just like bring costume changes for in between sessions?

Katie Vernoy  41:50

Hopefully not, hopefully not. I know that, that people who do a lot of these things back to back, find their professional attire, that they appreciate whether it’s, you know, a really nice comfy pair of jeans, and good looking tennis shoes or whatever. But I think it’s something where it may be appropriate to to have some changes of attire. But I think that also lends to, you know, making sure that you are not forgetting, scheduling and all those other things. So I guess we’re gonna talk about that in the next episode, but…but I think being able to show up on time, you know, with traffic or showing up, not out of breath, because you ran from the last walk and talk session, like I think all of those things, you know, there’s a lot to consider.

Curt Widhalm  42:39

So, being appropriate to each of the particular clients and cultural considerations as you’re going there. Let’s dive into the clinical work now. Like, how are we doing this? You know, it’s not just like, Alright, here’s the CBT workbook out in watching the band, or it’s not finger waving, like EMDR, while we, you know, walking backwards, like a college tour guides, like, what are some of the considerations that we’re gonna do here?

Katie Vernoy  43:12

Okay, so some of this is kind of the clinical how to, I got a great starting point from Cooley et al, 2020, ‘Into the Wild’: A meta-synthesis of talking therapy in natural outdoor spaces. I think it provides good information on the uncertainties of the settings. And I think it really a lot of it applies to home settings as well, obviously, some of this is, you know, I’ve got other stuff from other articles and from my own experience, but that’s really the the foundational article that kind of gave me the best practices as they were. So you want to start with the assessment and formulation. We’ve talked about this a little bit. But I think truly, and Curt and I are talking about putting together a full assessment kind of considerations worksheet for you, so we’ll have that with the course, when we put this out there. But I think that the first thing that you really want to look at is, is the client suitable. And so we talked about some of the flexibility and the ability to manage the relationship, but more specifically, are they physically suitable for it? Which we’ll talk about accessibility issues in our next episode. Are they clinically suitable, and are there potential benefits for you to actually do this treatment with them? And so really kind of everything we talked about, that is what you want. That’s the first kind of point of the assessment. You also want to make sure it aligns with treatment goals. And obviously, there’s a very broad array of treatment goals that could be helped or hindered by a non traditional therapy treatment, but like, specifically, if we’re looking at a client who has a lot of conflict with family, doing family therapy at the home, getting as many family members as possible could be very aligned with treatment goals. Whereas a client that’s wanting to learn individuation, going and meeting them in their home, you might be swimming upstream if the family is very kind of everybody’s present, and you’re trying to do some of that work. You also want to make sure you want to do a self assessment about your own characteristics. If you’re going to be outside, you want to have an affinity for nature, if you’re freaking out, every time you see a bog, that’s not a good match for you. You want to make sure that you have the flexibility to be able to navigate the different environments and you have to have some confidence about it. If you’re really uncertain, either going into a client’s home or going outdoors, you’re gonna have a hard go of it. Client characteristics for outdoor therapy, you definitely want to have them to have an attraction to natural spaces, unless you’re working on some sort of a specific phobia. You don’t want them freaked out in the environment. And even then, you don’t want them freaked out. Like it could be just like a kind of a ladder there.

Curt Widhalm  45:59

Sure. I think this might be an important thing. Let’s dive into what is the alignment with treatment goals? What do you mean by that?

Katie Vernoy  46:08

We’ll talk about kind of the client characteristics that might make this a better setting. And if it’s just client characteristics, it would not be necessarily most important to align it with treatment goals. But if it does align with treatment goals, it can be really, really rich and positive. And so when we look at aligning whatever the mechanism is, with treatment goals, I think it needs to be a match and needs to be a clinical match. And there has to be a rationale. Like if you’re just going outside, because it sounds like fun and the client doesn’t really care one way or the other and it then it negatively impacts the the treatment. Obviously bad. But if you’ve got a client who is trying to feel more embodied, they’re just ahead walking around, then they’re just all thoughts, no anything else, I think being able to be more physically active during a session and allow some more of that embodiment would be aligned with the goals, for example. I think for the home setting, you know, some of the alignment could be around helping them set up their own systems, and whether it’s managing executive functioning skills, or whether it’s interacting with the people around them, or whatever it is, I mean, certainly you’ve talked about, like ERP and eating disorders, you know, kind of the big ones that make the most sense. But even making sure that what we’re doing is in support of the goals and is not going to hinder the goals. Sometimes if that’s the only place you can meet like, it’s only home visits, there’s nothing you can do, and I think a lot of mental health, that’s kind of what it is.

Curt Widhalm  47:48

Sure, sure.

Katie Vernoy  47:49

You may be you may be swimming upstream, like I said earlier, but I think it’s, it’s something where if you can use the environment, as part of a, you know, and where you’re meeting and how you’re meeting in support, in direct support of the treatment goals, I think it can be very, very helpful.

Curt Widhalm  48:06

Okay, then, are there some clients characteristics that also are part of this conversation that may impact how well they’re going to respond in a non traditional environment?

Katie Vernoy  48:20

Yes, I think the clients who showed the biggest affinity for outdoor therapy already had an attraction in their natural spaces, or felt a healing, previous healing experience outside, or those types of things, you want to make sure that you’re assessing if they’ve had a trauma outside, or there might be triggers out there. I mean, that doesn’t necessarily preclude using an outdoor space, but you want to make sure that you’re thoughtful about it. If you have a client who is comfortable with having you into their home, and comfortable being at home, that helps to a certain extent, obviously, the reverse could be clinical fodder, and, and part of a treatment plan. And I think the other thing that I really found with my own clients is if there’s a discomfort with conventional therapy, they’re very excited about these other options. Because ‘I don’t want to sit still, for an hour, looking you in the eyes, like that sounds like torture, I’m never going to do that.’ And so for me, some of the clients just it was like, they become the big team themselves in doing that. And that was really exciting to see. Similarly, I think as clinicians, we need to if we’re going to be outside, we should have an affinity for nature and not be freaked out by every bug that comes by or be very flexible in how we interact with nature. And so we need to know that about ourselves. And so that assessment, I guess, is not one that’s necessarily in each individual assessment, but one that we want to make sure that we’re confident professionally that we can, can enter the space.

Curt Widhalm  49:54

Well, okay, so now you’re talking about the client and the clinician, go into one of my favorites things… There’s also the relationship here. There’s always spaces for shifts in relationships, if it’s adding or subtracting somebody from the therapy room, if it’s something where being in a different space, you know, a lot of us went through this in the pandemic of ‘saw people in person now we’re seeing you online,’ some people made that shift to doing walking talk at the time. What kinds of things have you seen or come across that talks about how that might shift that therapeutic alliance?

Katie Vernoy  50:33

Well, we talked about this a bit before, but I think in the assessment, you’re going to want to make sure that the client can navigate into a less formal relationship. And knowing more about you, I mean, I wear a hat, I wear a baseball cap outside, I certainly would not do that on the screen. And I’m not going to do that in my office. And so the lack of formality, the humaneness that you’re bringing as a clinician, and just navigating on the boundaries, I think I can’t emphasize enough how much that is important for you to assess for, can the client do this? One of the interesting things that happened is one of the clients that I, actually more than one of the clients, that I met outside, I had never met in person before. And so I found myself telling them like I’m tall. You know, this is, you know, it’s hard to tell when you’re when you’re online, I’m tall, you know, here’s my phone number in case you can’t figure out which one’s me, you know. So I think that there’s also that kind of, you know, kind of being together physically, that does shift that dynamic. You know, how I walk, I am a tall person, I have a long stride. So I try to mirror that and mirror the pace of my client. And like I said earlier, sometimes I try to slow them down, because they’re like going for a speed walk. And it’s like, no, no, no, especially when we were wearing masks like No, no slow down, you need to be able to speak. It’s something where the relationship can, I think really be very positively impacted. But it just has to be very conscious. I know, I’ve said that a number of times, but I think it just needs to be really conscious. So finishing the assessment, I’ll just kind of run through this really quickly, I think you want to, to kind of consider the presenting issues, I don’t know that there’s any particular that are contra indicated, I think that’s a case by case basis because the environments are so different. You might go to a home and end up being outside, you might be outside and then end up having to like shelter under a thing because of the rain like so like anxiety, folks that need ERP, depression, social phobia, isolation, a crisis, you know, I think a lot of those things, there’s not I’m gonna say rule of thumb, I think there’s going to be definitely some some need to to really assess your clients specifically, and how they’re going to do in this setting and whether or not it might stir up or exacerbate any of the presenting issues that they bring.

Curt Widhalm  53:10

Is that something that you would recommend a more evaluative process for a new client before doing this? And I think some of us who’ve worked with clients for a while we can kind of just look at somebody with one eye and be like, Yeah, you’re okay for walking talk therapy. But for somebody that you haven’t met before? Is there more of an evaluative process that you might go through during an initial intake phone call?

Katie Vernoy  53:38

With some of the new clients that I’ve brought it up with, I like to do the first session in person seated. And for me, I still have my office. So that’s where I choose to do that first session. And at this time, I’m still doing masks inside my office. So it’s a formal process. It may also be I would do it telehealth first, to have a conversation. Because I’m taking more notes, I’m doing more assessment, there’s just a lot of information for me in the way that I do my initial assessment that I have to get through in order to really do that. So during the phone call, as well as that assessment appointment, I would really talk about what it looks like, pros and cons. What do they think about it? If I felt like it was aligned at all with them. Some clients want to do it because it’s like, ‘Hey, I am sedentary all day, I would love to have an excuse to walk for an hour, while also taking care of this other need.’ It’s like multitasking. But some clients are like, ‘Oh, I would not want to be in public. There’s too much going on.’ And I’ve had clients that even we’re doing walk and talk and they’re like, ‘Yeah, I can’t cry in public,’ or you know, there’s something too deep to talk about. And so in the beginning of treatment, I think you’re going to want to assess what are they bringing in and if they’re at a high level of crisis, I think outdoor therapy or walk and talk may not be indicated because there’s so many other things that you have to control, and unless they are completely soothed by nature, and you know that they’re going to be okay, in the setting, there’s just too many variables. Crisis may be okay in their home environment, and it may feel less overwhelming for them for you to come to their home, less anxiety about going to treatment, because basically, they have to open the door, which could be stressful, I’m not, I don’t want to discount that. But it’s less potentially less stressful of getting out of your getting dressed, getting out of your home, going to an office, you know, what, braving traffic, all of that stuff. And so I think with those types of situations, you’re gonna want to be very cautious. But what I found with clients that I see mostly I see executives and, you know, leaders and helping professionals and stuff like that most of them, the level of crisis is fairly low. And so when we get through the thing, it’s basically talking about here, the different options, that I have that part of my informed consent, I see people on video, I have a walk and talk availability in the park nearby or in my office, and this is what it looks like. And I’ve got kind of the COVID requirements and all that stuff in that. And so if somebody shows interest in walking outside, I then dig deeper, but a lot of people just don’t know what it is, and aren’t that interested in it. And then you just don’t worry about it.

Curt Widhalm  56:14

So when we were talking about, you know, kind of having some plans of being out in the environments, like what are some of the considerations that you might want to look at? We talked a little bit about what’s out in the neighborhood, but I’m sure that that’s not everything that we need to think about?

Katie Vernoy  56:29

No, of course not. So once you’ve made the assessment, and you have a clear sense of kind of, if this is right for the client, then you then you want to formulate how you’re going to use the environment. Because it can be kind of this passive, we’re just walking, we’re not interacting with nature. And and if that’s the formulation, that’s a formulation, right? Like you, it’s just, hey, we’re outside, maybe use it for stabilization, maybe there’s metaphor that pops into your head, but it really is just kind of passively there, you’re building the relationship and something may come up, but you’re not actively using the environment.

Curt Widhalm  57:14

Okay.

Katie Vernoy  57:16

Now, alternatively, you can use the environment kind of as a third person in treatment and in nature that could be interacting with whatever it is, and so deeply interacting with it, it could be rituals, or different things that happen outside, that’s probably on the scope of this conversation, especially because we’re running low on time. But I think some folks actually have activities that they do with nature outside in nature that have their more creative activities, and you’re actually engaging with the environment. At home, that can look like, you know, setting up a homework station, it can look like having a family meeting at their kitchen table. You know, like there’s a lot of things that can happen where you’re actively engaging with the environment, versus using it as a place to meet. Does that distinction make sense?

Curt Widhalm  58:05

Yeah.

Katie Vernoy  58:07

When you’re out and about or are not tied to the two chairs in your office, I think that you can do roleplay in a different way, you can do some modeling within those things, whether it’s how you walk, how you do the different things. Like there’s there’s a lot of things that can happen, that with the physical mobility that happens with you entering their space, or them walking with you outdoors, that it just allows for more physical freedom to do a lot of different things,

Curt Widhalm  58:36

Getting to maybe some of the last pieces of structure here for clients. We have our normal informed consents. You and I have both worked on our own informed consents. We’re crafting some for maybe sharing with our audience here that takes the hits of both of ours, but what kinds of things do you consider adding into an informed consent here? We’re gonna get more in detail on this in part two of this episode as well.

Katie Vernoy  59:05

I think broadly, I think people need to know what they’re signing up for, that it’s voluntary. They can stop at any time. I think, you know, we’re going to have probably minutes and minutes of conversation on informed consent. But I think it’s something where, needless to say you need to have an informed consent specific or a portion of your informed consent specific to these types of settings, where you talk about risks, you talk about confidentiality, you talk about how voluntary it is, and then also potentially around the elements of them kind of being in charge of their own health and physical liability. But I think the big difference that I want to identify here is that once you’ve got the informed consent initially, it is more of a dynamic setup because of how uncertain the environment is. And so in this article it talked about process contracting, which is basically checking in, referring back and making sure that you’re continuing to assess the informed consent and shifting it if needed. And I’ve mentioned this before, I’ll mention it now, because I think this is really important, best practice is where you can introduce predictability. And so you’ve assessed, you’ve kind of formulated how you’re going to use it, you’ve created an informed consent, you do the process contracting to continue to assess and keep the informed consent valid. And then introducing predictability is really about where you can make things the same. And so I meet my clients at the same place. And we’ll talk about logistics of if you have back to back sessions, I have two different places that I meet my clients for walk and talk, for example. But you know, you try to make it so that there is some level of predictability. So you’re not constantly in the state of reacting to the uncertain environment, so that you can get a little bit more of that treatment space. And as in every space risk assessment is very important. It could be dynamic in a home, it could be looking at the relationship, and certainly if you are going to a home that has any kind of violence in it, or, or any kind of conflict, that’s part of the risk assessment. When you’re outdoors, it could be about like, is this path safe to walk on? It could also be about is this client up for walking today? Or do we need to, to kind of shift gears and do something different? I’ll say it again, you know, people can recognize that maybe there’s a question on this in the continuing education course… but you start with a strong assessment and formulation, you create a really strong informed consent. And then follow that with process contracting to continue to assess and check back on the informed consent, you introduce predictability, you make sure you’re doing appropriate risk assessment. And then the last point is know your scope of practice. And we will talk about this in the next episode. But just because you’re an experienced clinician does not mean that this is within your scope. And then also, think about consulting with experts. And this could be people in other fields like home health aides to make sure that if you’re meeting with a homebound client, for example, that you understand what’s happening with their physical health and how you can make sure that you’re not doing anything that’s going to be harmful to them. Occupational therapists, horticulturalists. If you’re going to do like a strong activity, that you want to use plants, you want to make sure you’re not using some sort of a poisonous plant where you both end up with like poison oak or something. But I think it even in how we take care of our own professional development and our scope of practice here really, potentially also requires some creativity.

Curt Widhalm  1:03:03

You can find out how to get continuing education for this episode, keep listening. We’ll post our links and references in our show notes. You can find those over at mtsgpodcast.com. And join our Facebook community, The Modern Therapists Group and follow us on our social media to find out about everything that we’re doing and places where you can share your ideas with us as well. And tune in for the next episode next week. Don’t forget to subscribe, and until next time, I’m Curt Widhalm with Katie Vernoy.

Katie Vernoy  1:03:38

Just a quick reminder if you’d like one unit of continuing education for listening to this episode, go to moderntherapistcommunity.com, purchase this course and pass the post test. A CE certificate will appear in your profile once you’ve successfully completed the steps.

Curt Widhalm  1:03:53

Once again that’s moderntherapistcommunity.com.

Katie Vernoy  1:03:57

Thanks again to our sponsor, Dr. Tequilla Hill.

Curt Widhalm  1:04:00

Therapist if you are tired of going in and out of the burnout cycle and you desire to optimize your wellness, Dr. Tequila Hill has created and curated a wellness guide specifically with deep compassion for the dynamic personhood of the psychotherapist. Subscribe to Dr. Hill’s offerings at bit.ly/staywellguide and you can find many of the inspiring offerings from Dr. Hill 17 years as a practice leader, supervisor, mentor, human systems consultant and wellness enthusiast.

Katie Vernoy  1:04:38

Once again subscribe to Dr. Tequilla Hill’s How to Stay Well While you Work! Therapist Wellness Guide at bit.ly/staywellguide

Curt Widhalm  1:04:48

Hey everyone, Curt and Katie here. If you love this longer form content and would like to bring the conversations deeper, please support us on our Patreon. For as little as $2 per month we’re able to bring you more content, exclusive offerings and more opportunities to engage in our growing modern therapist community. These contributions help us to expand our offerings for continuing education, events and a whole lot more.

Katie Vernoy  1:05:13

If you don’t think you can make a monthly contribution, no worries. We also have a buy me a coffee profile for one time donations. Support us at whatever level that you can today. It really helps us out. You can find us at patreon.com/MTSGpodcast or buymeacoffee.com/moderntherapist. Thanks everyone.

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