In the world of stereotypes, a counseling session goes something like this: The client lays on the couch, revealing his innermost thoughts to the therapist, who sits in a leather chair, glasses perched low on her nose as she slowly nods and inquires, “And how did that make you feel?”

In reality, though, talk therapy isn’t the only game in town when it comes to helping today’s clients. Active interventions of all kinds are gaining in popularity among counselors and clients alike.

In D.B. Palmer’s corner of the country, counseling sessions consist of everything from Nordic skiing to yoga to “walking sessions,” which are arranged like any other traditional 50-minute counseling session, except they take place along the 300 acres of trails at Alaska Pacific University (APU) in Anchorage, where Palmer serves as director of the school’s Counseling and Wellness Center.

Palmer, also a private practitioner and member of the American Counseling Association, remembers supervising counseling sessions with a client who was progressing well while engaging in cognitive therapy work with her counselor. “She mentioned one day to her counselor that while she felt competent in her thinking, she felt that something was missing and that she woke up each morning feeling anxious,” Palmer says. “She knew that she was overweight, eating poorly, not exercising and missed doing these things well. She just wasn’t committed enough to go do them herself. While I was supervising the counselor, I mentioned that this client would be a great fit for our walking sessions, and things have taken off from there. She’s feeling confident, losing weight, eating better, sleeping better, and her anxiety about these things is almost gone.”

With the Alaskan wilderness in his backyard, outdoor counseling interventions are a natural fit for Palmer’s work. But counselors who don’t live near rugged mountains or flowing streams shouldn’t automatically feel couch-bound either. Engaging clients in active interventions can take place just as easily inside the office.

Christopher Old, who runs a private practice in Truckee, Calif., entered the counseling profession by way of his background in experiential education. Although he harbors aspirations of eventually working with his counseling clients outdoors, for now, due to potential liability risks and logistics, his active interventions occur inside the confines of his office. Even so, Old finds that active interventions open clients to insights they might not otherwise arrive at through traditional talk therapy alone.

Old recently tried out an activity called “Minefield” with a teenage student client who was struggling to stay motivated and focused at school. On the floor of his office, Old laid out a number of “obstacles” in the minefield that the client had to avoid. Among the ways the client chose to label the obstacles: “showing off for friends,” “not managing time,” “not studying” and “having an angry attitude in class.” Old first asked the client to walk through the minefield with his eyes open and avoid the obstacles. Easy. He then instructed the student to close his eyes and try the process again. Not so easy that time.

When Old asked if the client thought he could walk through the minefield with his eyes closed and still avoid all the obstacles, the boy said no. So, Old said he would give it a try himself. The counselor closed his eyes but then did something the boy hadn’t thought of — asked for help in being guided through the minefield. “It was a total lightbulb moment for ‘Oh, I can ask people for help,’” says Old, a member of ACA. “In past therapy sessions, he had mentioned that idea about asking for help. But it didn’t really register with him until he saw it in action.”

The client took a turn navigating the minefield with his eyes closed while partly relying on Old’s guidance, and he was successful. In subsequent counseling sessions, Old noticed a significant difference in the boy’s behavior and attitude. “He would say, ‘I’ve got this thing I’m trying to figure out. Can you help me?’” Old says.

Active interventions are sometimes criticized for being merely “game playing,” Old says, but as used in counseling, the interventions have intentionality. Counselors who use active interventions also lead clients through processing afterward, assisting them in understanding how to apply what they have learned from the activity to their lives outside the office. To be effective with this approach, Old emphasizes that counselors must choose a particular activity for each client on the basis of the client’s specific needs and situation. “The main idea is that as the therapist, you tailor the activities and the debrief based on what the client is bringing into the session and what the therapeutic goal is for the session,” he says. “It is a very intentional use of activities versus just game playing.”

Seeing behaviors firsthand

As evidenced by Old’s and Palmer’s examples, active interventions can be very effective as part of individual counseling, but they also lend themselves well to group work. The unique benefits of conducting activities with groups are that the clients’ social interactions present themselves and the group members process what is happening and offer feedback, says David Christian, a doctoral student in the counseling program at the University of North Texas.

Christian, an ACA member who has used active interventions with children in a foster home and students at a local high school, says his work falls under the umbrella of adventure-based counseling (ABC), which he describes as the use of active interventions based in experiential learning as typically conducted in groups. “During ABC, the participants exhibit behaviors that are often the reason they are in counseling,” he says. “During the processing time, participants are able to receive feedback from the counselor as well as the group members on how their behavior impacted the group as well as the other individual members. The members are then able to explore alternative behaviors and ‘test drive’ them in future activities.”

Regardless of the age group or the size of the group with which the counselor is working, it is imperative to know about the group members’ needs, Christian says. With groups at the foster home, trust was a big issue with many of the children, so Christian chose activities designed to build trust rather than activities that required a significant level of existing trust to accomplish.

Active interventions allow counselors to experience clients’ behaviors firsthand instead of relying on accounts from parents, family members, teachers or other secondary sources, Christian says. Jeffrey Ashby, a professor in the Georgia State University Department of Counseling and Psychological Services, agrees. For instance, in watching a family interact through the course of an activity, a counselor can quickly see the same processes being reproduced that the family uses outside of the counseling session, Ashby says.

That real-life effect can make activities potentially powerful or destructive, so a counselor must be mindful of that, Ashby says, but at the same time, it’s helpful for the counselor to see the behavior reveal itself in session. “Clients will catch themselves being themselves [during these activities],” says Ashby, coauthor with Terry Kottman and Donald DeGraaf of Active Interventions for Kids and Teens: Adding Adventure and Fun to Counseling!, published by ACA in 2008.

The process surrounding the activity is the most important element to the intervention’s success, according to Old. From the start, he says, counselors must assess where clients are at currently and then, on the basis of that assessment, tailor an activity that will help them get to where they want to be. Before jumping into action, the counselor might choose to “frontload” the activity, Old says, introducing it to clients and describing where the counselor hopes it will lead. “Sometimes the introduction is nothing at all, and I won’t give them anything specific to think about,” he says. “But sometimes, I will. I’ll say something like, ‘Think about ideas surrounding communication when you’re doing this activity.’”

Depending on the intervention, the activity might run start to finish without setting time aside in the middle for reflection, so as not to interrupt the flow of the activity, Old says. In those cases, the counselor and client would debrief afterward. But in other instances, he says, a counselor might jump on an opportunity to shine a spotlight on something during the course of an activity. “Sometimes if [I] see things in the moment — a pattern or a dynamic that has been difficult — I’ll stop them and say, ‘What did you see just happen there? What effect did it have? What were you feeling?’ so that you don’t lose the teaching moment.”

Christian agrees, saying he’s learned not to get so hung up on the activities themselves. If a counselor notices something worth addressing during an activity, he or she should stop the group and talk about it, Christian says. Similarly, if a client has an “aha” moment while engaging in an activity, the counselor should let the client speak up.

Debriefing after an activity includes asking clients about what went on and what they experienced, Old says. “What you focus this discussion on will depend on the goals of the activity — remember the part about intentionality being important — and what happened while doing the activity. So, I will ask the client questions about what doing the activity was like and what was going on for them during the activity. We will talk both about behaviors — ‘What happened?’ — and thoughts — ‘What were you thinking about when you did this?’”

Old will often start the debrief with general questions and then move to more specific ones, especially if he needs to guide the client’s thinking toward the topic at hand. “For example, after doing an activity connected to the theme of reaching life goals, [such as with] the minefield activity, I might ask, ‘How easy or difficult was it to reach your goal in that activity? What made it easier for you or more difficult? What could you have done differently?’ I may also point out specific behaviors I witnessed during the activity and talk about those. For example, if I saw someone give up easily without asking for help, I might ask them about that: ‘What were you thinking about when you decided to give up? Did you consider asking for help at that time?’”

The nature of the debriefing segment might also depend on the counselor’s theoretical orientation, Old says. “For example, a CBT (cognitive behavioral therapy) therapist is more likely to focus on the thoughts going on during the activity. A solution-focused therapist might debrief focused on what worked well during the activity and how to do more of that. A psychoanalytic therapist might ask the client to tie what happened in the activity to what has happened in the past, etc.”

The final part of post-activity debriefing is to generalize the experience, Old says. “In this part of the discussion, I will ask my clients how the ideas learned in the activity can be applied to other situations in their life. For example, if a couple has just done a problem-solving activity successfully and we have discussed what led to that success, I will ask them about other problems in their relationship [to which] they could apply the tools they just learned. We will talk about what that would look like and maybe make a plan to give it a try. This generalizing part of the debrief really deepens the learning from the experience and helps client use what they have learned outside of the office.”

During debriefing, also known as processing or backloading, Christian follows David Kolb’s experiential learning model but adds a “therapeutic twist.” First, Christian discusses with the group what it did and asks the group members to tell him what happened. Next, they explore the “So what?” question. Christian says this question encourages group members to think about why the group did what it did and why things happened the way they did.

Then, Christian asks a final question: Now what? “During this time of the processing, we focus on transferring the new insights, knowledge and understanding to the clients’ everyday lives,” he says. “How is what we learned today relevant to their lives outside of counseling? I rely heavily on my counseling skills of reflection, active listening, summarizing and having established a strong therapeutic relationship with the clients.”

Counseling in the great outdoors

In his work at APU, Palmer’s clients at the counseling center include traditional college-age undergraduates, adult undergraduates, rural Alaskan Natives, graduate students, staff and faculty members, and associated family members of those groups. “It’s a wide population that covers our entire community,” he says.

The array of active counseling interventions Palmer offers is as varied as his client base. In addition to participating in Nordic skiing, yoga and walking sessions, Palmer’s clients can go running with him while they’re receiving counseling or take a retreat to the university’s 700-acre organic farm. In the spring, Palmer says the university will also be initiating a community garden where counseling sessions could take place. Palmer also offers workshops for clients on topics such as art therapy, relaxation techniques and stress management.

The university counseling center offers parent-child activity groups, in which students who are parents can bring their kids and engage together in play therapy activities facilitated by counselors in the gym or outdoors. “Students with children are often swamped with work, responsibilities of parenting and finances, and many Alaskan students are far from home networks,” Palmer says. “These sessions allow parents to reconnect, to learn from counselors and to have a safe place to play with their kids.”

Faculty and staff wellness is also prioritized on campus, Palmer says. Faculty and staff members have access to the same services offered to the students. They also get time off each week to take part in wellness events and programs, including dodgeball, botany walks, snowshoeing, canoeing and more. “APU employees recognize that doing our jobs well means staying fit, and that means mentally as well as physically,” Palmer says. “All staff and faculty are afforded free services through my office, [including] walking, running and skiing sessions.”

Counselors at the university attend and facilitate during university block courses, Palmer says, including a swift-water guiding course, an introduction to wilderness skills and winter leadership skills. In addition, Palmer offers a wilderness therapy retreat series to students and mental health practitioners on topics such as leadership skills, professional counseling skills, and mindfulness and ecopsychology.

All the active interventions Palmer leads through the university are activities he independently offers to his private practice clients as well. In addition, through his private practice, he takes clients on seasonal treks, including sea kayaking, rafting, dogsledding, backpacking and canoeing. Palmer also offers four- to seven-day wilderness/adventure-based counseling treks for individuals, couples, groups and families.

“The range of benefits are very wide,” Palmer says about the treks. “Primarily, we work with a parent and child. However, we are getting more calls for entire families and couples. We work with each family to determine [its] needs and design a custom program. These programs can include options such as dogsled expeditions, rafting or canoeing trips, or backpacking options. Every option is unique, and I pay special attention to the family’s needs and goals in designing each trek.”

An example of a one-session activity Palmer often uses in private practice is adventure hiking. “We don’t plan any particular route, as we’re not running an outfitting business,” says Palmer, whose wife, Greta, is a partner in their practice as a personal fitness counselor and life coach. “We take hikes in our local mountains. Anchorage has lots of mountain trails, and these trails are heavily used by our adventurous residents. We’ll meet up at the trailhead, check our gear, as we’re both responsible for our own gear and safety, and head out for one to two hours of hiking. We can tailor these sessions from mild to extreme difficulty levels, while engaging in our session.”

With most of the activities, including walking, Nordic skiing and trail running, Palmer says the counseling session takes place during the activity. Perhaps surprisingly, Palmer says he hasn’t found the activities to reduce the amount of conversation possible. “In fact, I’ve found that our activities clarify and expand the thinking process and thus, the therapeutic dialogue is greatly enhanced,” he says. “Our active sessions also have the added benefit of adding a construct to our session. With a walking session, the client can breathe the fresh air, reflect on environmental stimuli and notice the interactions that occur around us. For example, if we are walking past a park bench with an elderly couple sitting and talking, the client may reflect on their own parents, grandparents, their marriage, their children and their own hopes for the future.”

Palmer says he merely mentions active interventions as an option for clients rather than having every client engage in them automatically. As more people come to recognize the links between wellness and mental health, clients have also asked him about active options during the intake process or phone screenings.

In addition to his counseling credentials, Christian is a level-one certified challenge course facilitator and has facilitated ABC on ropes courses. Challenge courses can offer therapeutic opportunities for counselors and groups, Christian says, particularly in areas such as life metaphors, goal setting and teamwork. One downside, he says, is that many counselors might not have easy access to nearby challenge courses. Counselors must also complete required training if they want to facilitate on the courses, Christian points out.

Take it inside

Although it can be an advantage to get outside with certain clients, Ashby says that’s not always possible or even necessarily the best strategy in all cases. For instance, in a school setting, he says, going outside is a form of breaking confidentiality. And even in other settings, he says, it can be problematic to go outside because of the difficulty of anticipating how private an outdoor space might be.

Inside Old’s office, he uses another active intervention called “Linked Together” from time to time with pairs of clients. In the exercise, two ropes, each with a loop on either end, are linked. Each person puts one loop around each wrist, and the object is to get the two ropes disconnected without taking the loops off either person’s wrist.

The exercise works on problem-solving and communication skills, Old says, adding that each person can actually complete the task of disconnecting without help from the other person. “It’s a great metaphor to looking within ourselves when we have a conflict with someone else or a problem we’re trying to solve,” he says.

Another activity Old uses in his office is the exercise of juggling beanbags. Teens and kids find this challenge especially fun, he says. “I’ll teach them to juggle and connect it to what they’re juggling in their lives,” he says. Old will also ask reflective questions along the way such as how did you learn to juggle those things and how do you react when you drop a ball?

Old is a big believer in learning by doing, and he incorporates team-building-type activities into counseling sessions to bring the ideas he and his clients talk about to life. “For example, if a couple is talking about trust in their relationship, I might have them do forward and backward trust leans in the session and then process what the activity was like for them,” he says. “What did they feel while doing the activity? What effect did communication have on trust? How do they build trust in their relationship? We then use the activity as a metaphor during our work.”

With groups at the local high school, Christian uses an activity known as the “Name Juggle.” Group members pass tennis balls or beanbags to one another while saying each person’s name. With a recent group, Christian told group members the tennis balls would represent things that helped them to be successful in school. The group had to follow a pattern of throwing to each person in the group, and Christian gradually added more balls into the mix.

Partway through the activity, and without warning the group, Christian brought out a rubber chicken and threw it into the pattern. “People get distracted and the balls go flying everywhere,” he says. “So we talk about what are the rubber chickens in their everyday life? What things distract them in school and cause them to drop the ball, so to speak? It creates a reference point, and in future sessions, you can ask what rubber chicken they encountered and how they handled it.”

Shaking things up

Although Palmer says he still really enjoys traditional talk-based counseling sessions conducted in an office, he believes the potential benefits of active sessions are immense. “Why [engage in active interventions]? First of all, we sit too much,” Palmer says. “The benefits of exercise are not only based in timeless wisdom but also represent the latest in neuroscience. Just 25 minutes of exercise a day provides a significant dose of natural antidepressant within our bodies, not to mention the physical and overall health benefits.”

Outdoor sessions in particular provide a jump-start to clients’ thinking, while also offering them connection to their surroundings, Palmer says. He also believes that getting active and getting outside does much to improve counselor performance and the counselor-client relationships. “[Counselors] are far more perceptive when we get off the chair,” he says. “When I walk with my clients, I feel more connected to their stories. The power differential is shifted. Clients see me in a new environment, one in which I navigate the world alongside them. We share the weather, the sights and sounds, and we connect on a deeper level. Active sessions shake things up.”

Active interventions, including adventure and wilderness therapies, are shown to be highly effective with a wide range of presenting issues, Palmer says, including depression and mood disorders, anxiety, personality disorders, grief and loss, post-traumatic stress disorder, eating disorders and low self-concept, as well as with clients who have experienced abuse.

The counselors interviewed for this article contend that almost any client can benefit from active interventions. Including an activity adds a dynamic to therapy that children and adolescents typically regard as more fun than just talking, Old says, and as a result, they tend to be more willing to engage. On another point of the age spectrum, active interventions can help entice adults to step out of their comfort zones, he says. Active interventions can also provide counselors with a clearer picture of how clients act and interact outside of the session, Old says.

Christian, who frequently works with adolescent males, says active interventions are the best approach he has found for getting through to these clients. Boys are more likely to drop their guard, open up and communicate through their actions rather than solely through talking, he says.

Families can also benefit significantly from active interventions, Christian says. “It’s great to watch families have fun together. I love seeing them interact and learn about each other. Processing is always a powerful experience with families. Families also usually start to incorporate more activities outside of session, which is great for communication, cohesion and trust.”

Palmer says another positive is that the stigma clients sometimes attach to counseling is greatly reduced when sessions don’t center on talking inside an office. “I can meet my clients at the trailhead, on the path [or] at the parking lot rather than at my office under the sign that says ‘Counseling Center.’ For all anyone knows, we’re just two peers taking a walk in the park,” Palmer says.

Taking precautions

These experts encourage counselors interested in using active interventions — whether office-based or outdoor-based — to seek proper training before delving in. “Like any other intervention, the counselor should be competent in the activity utilized and the limitations and advantages of the intervention,” Palmer says. “There are logistical and pragmatic concerns like confidentiality — such as, ‘How would you like to introduce me if we come across friends?’ — but these are also concerns discussed in traditional sessions.”

Palmer is a certified wilderness first responder, but he points out that training is far more than the typical counselor needs to simply take a client on a paved walking path for a counseling session. He does recommend, however, that counselors research their options and consider training with an advanced practitioner.

Old mentions the Therapeutic Adventure Professional Group, part of the Association for Experiential Education, as one option where counselors can seek out workshops and conferences. In addition, he says, Naropa University in Boulder, Colo., offers a master’s degree in transpersonal counseling psychology with a concentration in wilderness therapy.

Christian points to Project Adventure, which he says offers introductory courses in ABC. For those counselors interested in ABC, training in group work is also paramount, he says. As for those interested in challenge course work, Christian encourages them to earn certification through an approved Association for Challenge Course Technology vendor.

Ashby cautions that counselors should also be mindful that, depending on how active an intervention is and where it’s taking place, additional informed consent or liability waivers might be necessary. For the APU counseling center’s walking sessions, Palmer and his colleagues primarily depend on the informed consent document as well as information gathered from intake materials, which inquire about clients’ medical conditions and detail restrictions concerning the activities the counselors offer. “We include the standard doctor clause: ‘Be sure to check with your medical provider if you have questions about whether or not active sessions are appropriate for you,’” he says. For adventure-based treks, Palmer acknowledges that the liability waivers are more complex, but he advises counselors against attempting to jump directly into that level of activity.

When using active interventions, these counselors emphasize that clients’ emotional and physical safety is of the utmost importance. Old cautions counselors to know for certain that each client can be trusted to be safe in the activity before doing it. “If you have a teen who you know will drop his dad on his face in a trust lean, then you don’t do a trust lean,” he says. Old says he always talks with clients about safety concerns before an activity, and he always gives each individual client the option of not participating.

Says Palmer, “For counselor safety and accountability, we utilize a unique call-in system to alert each other that we’re beginning and returning from our active sessions, as well as traveling an established and approved route. Personal as well as psychological fitness is essential. This is not something to just decide to do. I have taken very deliberate steps, researched the broader field, consulted with leaders and built upon over a decade of practice and academic research. Like any new specialty, the new counselor must be aware of the implications upon practice.”

Respecting the entire therapeutic process is also key, Old says. If the counselor fails to choose the activity based specifically on where the client is or doesn’t debrief afterward, the intervention will end up being less powerful, he says.

But for counselors who put the work into researching and training with active interventions and then put them to work in their practice, the payoff can be significant, these counselors say. Beyond improving physical health and fitness for clients, Palmer says active interventions enhance the rapport between client and counselor and promote therapeutic advances. “For some clients, this is one of the only ways to break through depression and anxiety,” he says. “Some clients are so entrenched in behavior and thoughts that keep them in the same place. Active sessions are phenomenal in their ability to drive through these barriers.”

Christian’s faith in the effectiveness of active interventions continues to grow stronger. “Although there is not an abundance of research regarding ABC, given what we know about cognitive development, the effect of exercise on the brain and personal antidotes, ABC proves to be an effective form of counseling,” he says. “Also, you don’t have to go to a ropes/challenge course to do active interventions. ABC is adaptable to nearly every setting. I would love more counselors to learn about it and begin to utilize it.”

 

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Both Palmer and Old are happy to offer trainings to other counselors. For more information or to contact them, visit Palmer’s website at abcfamilytherapy.com and Old’s website at mountainmentalhealth.com.

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Walking the Labrynth

Not surprisingly, the campus of Central Michigan University doesn’t feature an ancient outdoor labyrinth. So Michelle Bigard has her clients at the university’s counseling center tap into the therapeutic benefits of a 24-foot indoor canvas labyrinth instead.

Bigard, a counselor and associate professor, describes labyrinths as meditative walking paths that feature a circle to represent wholeness and unity, a spiral to represent transformation and change, and a quadrant to represent order. “So you have change and order in a safe setting, which is why we think it’s such a powerful symbol,” she says.

Historically, there are two main labyrinth patterns: medieval and classical. A classical labyrinth has fewer paths than a medieval labyrinth, Bigard says, so a classical labyrinth can be helpful in moving larger groups through more quickly, whereas a medieval labyrinth can lend itself to a slower, more contemplative walk. Both labyrinths styles are useful in either individual or group work, Bigard says, because they assist clients in slowing down and becoming more self-reflective and self-aware.

The idea is to walk toward the center of the labyrinth, reflecting and remaining open to what thoughts and images come to mind, Bigard explains. When people reach the center, they can stand or sit for as long as they want before walking the path back out and exiting.

Bigard encourages clients to remain open to the experience and to the metaphors that often reveal themselves. “If the narrow turns drive you nuts,” she says, “you can reflect metaphorically on that: ‘Where are the tight turns in my life?’” The hope in doing the exercise, Bigard says, is that clients will learn something about themselves and figure out how to apply that knowledge in their lives.

Whether individually or in a group, after clients finish walking the labyrinth, they can process the experience with the counselor. Bigard says counselors who do labyrinth work ask clients processing questions such as “What metaphors showed up for you? What meaning does this have for you? How do you want to apply what you felt or learned [in the labyrinth] in your life? What’s it like to hear someone else had a similar experience in walking the labyrinth?”

Labyrinth work can be relevant for almost any type of client, Bigard says, but she thinks it’s especially helpful in situations of loss, change, transition and trauma. Among trauma survivors, a spiritual wound and a wound of trust often exist, Bigard says. The labyrinth offers clients dealing with trauma a safe and containing place that is enclosing but not engulfing, she says.

But labyrinth work isn’t beneficial only to clients, Bigard says. It can be useful to counselors in their own self-care as well. Counselors can walk a labyrinth to enhance their stress management, self-awareness and personal growth, she says.

Bigard suggests that counselors interested in leading labyrinth work first try it out for themselves and also undergo training. She points to a facilitation process through Veriditas (veriditas.org) as one option for training.

— Lynne Shallcross

 

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Lynne Shallcross is a senior writer for Counseling Today.

Letters to the editor: ct@counseling.org