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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.

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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

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

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.“

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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 WalkandTalk.com.

“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.”

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