MORNING, SO the fog still hadn't lifted for the day. Two men, looking much like a father and his grown-up son, walk up the hill. They each face forward, engaging intently in conversation. Do they have a destination in mind? Only they know. If the fog were to lift, then the pair's view from the top of the hill, of the city and the bay, would be magnificent.
The Tunisian-French psychoanalyst Gérard Haddad suggests that psychoanalysis needs to name a drive in addition to the oral, anal, and genital. He termed it pulsion viatorique (from Latin viator, meaning traveler)—the walking or ambulatory drive. Before we are speaking beings, we are walking beings, notes Haddad. The Oedipus story begins with a father maiming his son's feet so that he cannot walk; the very name “Oedipus” means “swollen foot.”
A rising number of psychotherapists with disparate training in social work, mental health counseling, and psychology are finding themselves in scenes like this one—albeit in a variety of geographic settings. To enhance the therapeutic alliance, to foster connection with the social and natural world, to unsettle power dynamics at play in traditional therapy, and to ameliorate some of the problems with seated therapy (e.g., physical pain), therapists are increasingly turning to walking therapy. Their patients include some of the millions who moved to telehealth treatment around the time of the Covid-19 pandemic—patients now seeking treatment that is not only in person but in motion.
This summer, I spoke with more than a dozen therapists who have implemented walking into their therapy practices, either on an ad hoc, as needed basis or as one of the core elements of their work. Therapists are walking with their patients in Central Park in Manhattan and Prospect Park in Brooklyn, in the suburbs surrounding DC, across rural hamlets in the UK, on the beach in Los Angeles County. Many of these clinicians are passionate about movement and energized by the work they are doing outside with patients. But the psychotherapeutic community still lacks a cohesive framework to think about what walking offers the therapeutic dyad. Psychoanalysis can contribute to that framework, helping us think about how and why we might want to get out of the chair and walk.
Walking therapists come from a range of backgrounds, but they tend to work in private practice, live in more suburban and rural settings with greater access to the outdoors, and market themselves to physically active patients who are already familiar with walking or running for pleasure. By and large,
they do not work psychodynamically, skewing instead toward so-called evidence-based approaches.
But walking therapy need not be limited to the patients of non-depth therapists. Walking is an accessible approach that can treat an array of patients, even those experiencing mild or moderate chronic pain. Indeed, for some it can directly alleviate pain symptoms.
Psychoanalytic and psychodynamic clinicians remain curious but hesitant about working in this way—suggesting, perhaps, an intrapsychic conflict. Psychoanalytic constraints, or “rules,” create anxiety and keep therapists sitting down. Aleksandra Wagner, a psychoanalyst and professor emerita at the New School, suggests that analysts usually start their thinking about walking therapy from a point of repression: from the assumption that we should not be doing it. These limitations are imposed from the very first phrases that a therapist so often utters to a patient: “Please take a seat.”
What if the psychotherapeutic space were not handed over intact by the therapist but rather created as we walked? In her critique of the psychoanalytic concept of the containing space, Martyna Chrzescijanska suggests that the therapeutic space looks less like Bion's theory of the container/contained and more like the outer landscape and the patient's associations to it. Though psychoanalytic language—including the holding environment and the container/contained—tends to reference the mother's relationship with her infant and the womb-space she provides, the field of psychogeography helps rework the concept of containment by thinking about how the quality of open attention works in the outdoors. Psychogeography, after all, originated in the 1950s in the ideal of the aimless walker, the flâneur, walking without knowing where they are going.
For Lara Just, who provides outdoor therapy in the UK, “paying attention” works differently outside than it does inside. Outside, the natural world becomes a co-container. The landscape situates patients within a more expansive context of relationships in the social and natural world. This transforms Just's ability to hold the patient, helping her feel more expansive and less isolated as a practitioner. Patient, therapist, and nature all play a key role in the relationship. Rather than attempting to “extract the peace and calm of nature,” the dyad expands to a triad that respects and considers the earth. This is Just's quiet resistance to the disembodiment, distraction, and despair of our times.
Psychoanalysis is no stranger to the struggle against disembodiment. Fernando Castrillon—clinical psychologist, personal and supervising analyst, and professor emeritus in the Community Mental Health Program at the California Institute of Integral Studies—has found that in recent years, more and more of the young people coming in for analysis “have a rough time speaking and instead speak through the body.” These patients may have somatic complaints but have difficulty speaking about what, in particular, ails them. These treatments require preliminary work, a kind of preanalysis, to help patients begin speaking.
All too often, Castrillon and I mused, therapists, even psychoanalysts, have the same issue: They fall for the mind-body divide, the old split. When we talk about “walking therapy,” therapists tend to focus on the physiological benefits of movement—improving cardiovascular fitness, for instance. But by focusing on physiology, we split body from mind.
From Berkeley, Castrillon rhapsodizes about the archeological record of the human capacity for walking: the way human anatomy and physiology—how our spines meet our skulls to enhance our balance, the location of our eyes in our face—are all set up for us to walk and run, to hunt and gather. Psychoanalysis forgets that. It represses the fact, the memory, that for hundreds of thousands of years, our capacity to think occurred in movement, via walking or running. “If we're not engaging in shared movement,” Castrillon said, “how do we work through things?”
To be clear, walking in therapy doesn't mean on a treadmill inside an office. It means walking outside, in the world, together. There is more than physiology at work here—more than bilateral stimulation or the benefits we reap from getting our blood moving. For a Lacanian like Castrillon, an analytic treatment at its best can attend to the Real of the body—the dimension that resists symbolization and eludes meaning. But body is psyche. And this is a psychic process, Castrillon argues. “When a patient is walking,” he says, “they are speaking.” The body is being used to help the patient speak and associate.
When Noah Miska walks with private practice patients in Prospect Park, for instance, the body is brought into sharp focus, with all its heightened and clarified “implications for transference and countertransference,” as psychiatrist Cathy Schen puts it. Bathroom options are limited in the park, and sometimes, someone may have to relieve themself outside. “Out in the world,” Miska said, “the messiness of a body is more present.” Sepideh Saremi, a psychodynamic therapist who emphasizes the relational processes at work during walking sessions, adds that “there is still plenty of transference” in walking therapy—“but I feel less intrusive as a therapist.” Side by side, patients may feel less pressure to make eye contact. The therapist is not perceived to be “scanning for judgment.” In some ways, then, walking represents a return to—rather than a departure from—the couch, since Freud did not meet his patients' gazes as they lay in his office.
As a medical doctor, Freud had extensive knowledge of the body, and he believed that physical movement facilitated insight. He did not ignore the bodies of his patients who arrived to him displaying somatic symptoms. Among the second generation of analysts, Wilhelm Reich also wrote extensively on attending
to the body during analysis, and he and his followers used (at times questionable) body-focused exercises and protocols. But as psychoanalysis moved from Freud's couch to offices across Europe and the United States, what took off was his and Josef Breuer's “talking cure,” not their “walking cure.”
“Limitations are imposed from the very first phrases that a therapist so often utters to a patient: ‘Please take a seat.‘”
Fundamentally, the psychoanalytic method was invented for the couch, not the street or the park. Freud believed the couch facilitated the emergence of unconscious material. The couch allowed for intimacy to develop between therapist and patient without breaking Victorian-era norms around physical proximity or touch. When walking together, the therapist and patient are closer than they usually are when sitting in a room together; we can imagine them bumping shoulders, as if on a romantic evening stroll, about to stop for a drink. As the practice of psychotherapy was developed and standardized, the profession also emphasized the transference relationship and the importance of establishing boundaries between therapists and their patients—leading therapists to favor working in more “controlled” indoor settings, as counselor Stephanie Revell notes.
Yet this history leaves out the fact that Freud himself did walk. He walked with patients around the university in Vienna and even conducted a few walking analyses: of Max Eitingon in 1907 and of Gustav Mahler in 1910. Mahler's analysis took place in Leiden, while Freud was on holiday at a coastal resort. Freud walked with Mahler for four hours among Leiden's canals. Mahler was suffering from heart disease, in distress over his own sexual dysfunction and the pursuit of his wife, Alma, by Walter Gropius. Legend has it that the analysis was a stunning success.
The literature tends to credit Thaddeus Kostrubula as the first therapist to embrace and disseminate walking therapy. Kostrubala was known as “the running psychiatrist” and practiced what he called “running therapy.” He found running—any pace between an ambling walk and a full run—helpful for patients dealing with a range of psychological concerns including depression, anxiety, psychosis, and addiction. As a clinician, Kostrubala felt hemmed in by the indoor setting and found its required seated positions passive and restrictive for both members of dyad. Running therapy, meanwhile, seemed to foster a more equitable relationship. Outside, the therapist was no longer in charge of the setting or all the rules. The patient could literally direct the course or path of the treatment. The approach unsettled the power differentials between therapist and patient by involving them in joint movement and shared rhythm, facing the same way and moving in the same direction.
Kostrubala's “running therapy” terminology has largely been left behind, but walking therapists still echo many of his beliefs. Jennifer Udler, a social worker and founder of Positive Strides Therapy, felt restricted in the office. In her current work, she and her patients look out for each other in the space they share outside. “It's not ‘my office, my chair, my rules.‘”
Many of the clinicians I spoke to first became curious about walking with patients after having positive experiences of walking, hiking, or running in their own lives—such as listening to a reticent friend who suddenly opened up on a walk, or noticing how good they felt after spending a day walking in the woods. Others came to it during a time when walking was the only thing keeping them going. Lara Just, for instance, only began walking therapy after a painful divorce, when she couldn't imagine going back to a typical office. Plus, finding clinical space was becoming prohibitively expensive in her area. Udler, meanwhile, intuitively added walking to her practice before she came upon research and a wider community already using the approach. She is now an administrator of the Facebook group “Walking, outdoor therapists,” which formed seven years ago for members to offer each other clinical support and has more than 700 members.
Some of these therapists have full walking caseloads, while others have walked as more of a one-off, perhaps during the Covid-19 pandemic or in response to an episode of acute back pain. Some walk with any patients, while others specialize in a particular population—new parents, for instance, who may feel isolated at home and who often bring infants along for sessions. Over and over, I heard about patients who reached an impasse inside and only broke through after moving outside. Udler was reminded of one child patient with depression. While walking, the boy was “a different person. I did not see the depression; I saw an active kid who had a lot to tell me.”
Patients value the work. Saremi finds that patients increasingly “want this type of relational practice.” Based in Redondo Beach, California, she founded and currently runs Run Walk Talk, which offers a directory of walking providers and a 12-week training program in walking therapy.
And clinicians often repeat that they feel lucky to walk. While outside, they find they feel more present in their bodies. It can be uncomfortable or taboo for a therapist to consider moving outdoors for her own benefit or to center her own preferences. But Udler believes that walking “makes us better therapists … We're more alert, doing our best thinking.”
After back-to-back sessions in the park, Miska feels “good in body and in spirit. Physically tired and physically well.” How many workers, let alone therapists, can say that?
“Many of the clinicians I spoke to first became curious about walking with patients after having positive experiences of walking, hiking, or running in their own lives—such as listening to a reticent friend who suddenly opened up on a walk, or noticing how good they felt after spending a day walking in the woods.”
Walking doesn't always work, and Castrillon cautioned about treatment specificity. In Castrillon's own analysis, his analyst only suggested walking towards the end of the several years they spent together, when Castrillon was having difficulty, as he puts it, inventing his way off the couch. Castrillon credits walking together with his ability to end the therapy—in Lacanian terms, to get rid of the father on account of using him. Walking, he believes, was “well timed” in his analysis.
Many clinicians express concerns that walking therapy might be safer for people who are “resourced,” or relatively untraumatized. But seated therapy can pose its own risks to patients with trauma, who can dissociate or else become dysregulated or overwhelmed in the indoor setting. For these patients, office walls may feel “oppressive,” writes Nick Tarrant, “the closeness and expectancy of the therapist too intense.” Others find that walking side by side makes the work less intimidating, thereby reducing the emotional barrier to entry.
Saremi, like Castrillon, started off in the community mental health setting, working with Iranian immigrants seeking culturally appropriate care delivered in Persian. Some of these patients were torture survivors for whom the cinderblock walls of the office, Saremi said, were a reminder of their interrogations. For some patients, making eye contact with a woman while sitting across from her in their living room during a home visit was neither culturally appropriate nor comfortable. As a patient, Saremi identified with patients like these, who struggled to get in the door for therapy. Walking therapy, on the other hand, was less intimidating.
Walking therapy can even be indicated for patients with psychotic spectrum disorders. While a closed room seems inherently containing, Aleksandra Wagner notes that for people experiencing psychosis, walking outside can be containing. According to Leston Havens, purposeful side-by-side positioning of therapist and patient can reduce a psychotic patient's paranoid and hostile projections.
In the first years of his work as a clinical psychologist, Castrillon primarily worked with patients with schizophrenia. He remembers suggesting a walk to one very quiet patient with psychosis. The patient jumped at the idea. They walked by a greenhouse nursery; the patient was “transfixed.” He started talking. “The more we walked, the more he spoke,” Castrillon said. The patient was able to use their shared movement, and their shared landscape, to begin articulating what he had previously been unable to articulate.
Therapists can walk with psychotic patients in many settings, of course—from inpatient hospitals to outpatient private practice. Much of the work takes place in community mental health settings, however, among clinicians who Saremi says have “done this work forever without getting credit for it.” Even when institutions have not provided clear guidance or training, these workers have been “scrappy and resourceful.” Noah Miska, for instance, began walking while he was a case manager for unhoused patients camping out in rural Oregon. Walking, Miska says, provided “freedom.”
Other models of walking therapy exist globally. In the 1960s, as part of the psychiatric reform and antiasylum movements, clinicians in Argentina began treating chronic patients who did not adapt to traditional treatments through an ambulant clinical approach called therapeutic accompaniment, or TA. The practice spread to Brazil, first at the Pinel Clinic in Porto Alegre and then to Rio de Janeiro and São Paulo. The approach taken up in Rio was more strongly influenced by psychoanalysis than by the American community model. TA is still relatively widespread in São Paulo, especially in psychoanalytic circles, and is mainly offered as a free public service.
TA aimed to help socialize patients during the psychiatric reform movement. In the US, mental health service users experienced a similarly drastic shift in their spatial lives during the period of deinstitutionalization in the mid-20th-century, which saw the closure of numerous state-run asylums. But TA did not find intellectual or institutional roots here in the US. In Brazil, the approach has since expanded to treat a wide range of patients: the elderly, children, and people with phobias, depression, panic, autism, or schizophrenia.
Therapeutic companions (acompanhantes terapêuticos) accompany the patient in their daily tasks and activities. The boundaries of the practice are not limited by the room or hospital's walls. Rather than trying to draw the patient out, as it were, TA aims to immerse itself in the patient's individual universe. The “listening apparatus” of the therapy becomes the whole body and everyday life. Instead of a patient trying to represent their internal world, their internal world is presented in the physical world. Once again, in Lacanian terms, TA hews closer to the Real.
Léo Tietboehl, a psychoanalyst and psychologist based in Rio Grande do Sol who has done TA on occasion, describes how important the body is to TA. Many years ago, Tietboehl worked with a 40-year-old man with multiple disabilities who used vocalizations, but not language, to communicate. The patient, who had psychosis, was “not used to having a choice in where he went,” Tietboehl said. He was rarely free from other people's gazes and had little autonomy to explore public space, having never left home without a family member's company. When they met for a session, Tietboehl would stand back to allow the patient to choose the route. Therapist and patient were able to communicate through the direction of the walk that the patient chose. The risk of interference or disruption was always high. But TA embraces that reality rather than pushing it away.
Perhaps the closest thing to TA happening in the US, as I see it, is the street therapy provided by mobile clinic teams. In New York City, Natalie Casagran Lopez works on an intensive mobile treatment team for patients with serious mental illness, who are often experiencing psychosis, substance use, and high levels of social precarity. For the most traumatized, being inside may simply not make sense. Many are not comfortable inside, while others walk miles every day to stay warm, seek services, or alleviate boredom. In some cases, being alone with a clinician in a small space might only exacerbate trauma. Casagran Lopez describes how, “for people who have been chronically institutionalized with little living space—living in a hospital with a roommate, or incarcerated, with a cot in a room full of 50 other men,” walking outside is the very thing that allows access to expansiveness in a therapeutic session or visit. The city's streets provide the holding environment.
This work requires therapists to “go with the flow of the changing environment,” says Casagran Lopez. Therapists work on the patient's clock and must be sensitive and responsive to a patient's pace. Some days that might mean accompanying a participant at the mouth of a tunnel, dodging traffic as he solicits money from commuters in their cars; other days, it might mean squatting or sitting on the curb together, in a place where comfortable benches are few, far between, and diminishing every year. Every session, therapists are forced to confront and understand the physical world their patients inhabit, as well as the dynamics of status and class. Like in TA, street therapists “immerse [themselves] in the patient's individual universe.” Patients, meanwhile, are given the choice not to assimilate. Tietboehl says that in therapeutic work like this, patients with psychosis are not required to constantly try to adapt to their environment.
The work is certainly susceptible to intrusion or interruption, as in TA. But the “intrusions” of the environment become part of the dialogue, and Casagran Lopez says that can take the edge off the pressure to process or quickly disclose intimate information. It also allows for more dynamic free association. These aspects of street therapy—the landscape's holding capacity, and the way that therapeutic space is constructed via the patient's associations—echo Chrzescijanska's turn toward “psychogeotherapy,” introduced above.
The reality is that not all patients deserving of psychotherapy live in areas with access to good walking paths or magnificent, awe-inspiring nature. Our cities are often banal, inconvenient, and marked by structural violence. For people who live in unsafe settings, walking may at times pose more risk to the therapeutic relationship. For both patient and therapist, however, walking through a local landscape “imbued with social suffering and traumatic memory,” as Lena Sawyer and Kris Clarke write, may open up new ways of experiencing that place. This risk seems worthwhile given its dual potential to leave room—space, even—for the therapy: for healing, growth, and transformation.
Lily Meyersohn is a psychotherapist in New York City. Her writing has been published or is forthcoming in Parapraxis, The American Prospect, The Los Angeles Review of Books, and elsewhere.