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. 2025 Feb 5;32(1):e70035. doi: 10.1002/cpp.70035

Walk‐and‐Talk Therapy Versus Conventional Indoor Therapy for Men With Low Mood: A Randomised Pilot Study

Andrea Dickmeyer 1,2, Jordan J Smith 2,3,4, Sean Halpin 1,3, Stacey McMullen 1,3, Ryan Drew 2,3,5, Philip Morgan 2,3,4, Sarah Valkenborghs 2,3,5, Frances Kay‐Lambkin 3,6, Myles D Young 1,2,3,✉
PMCID: PMC11795730  PMID: 39907105

ABSTRACT

While psychotherapy is effective for treating depression, men are less likely than women to attend and more likely to drop out. The value of alternative therapeutic approaches for men needs to be investigated. In this randomised pilot trial, we investigated the feasibility and preliminary efficacy of outdoor ‘walk‐and‐talk’ therapy compared to conventional indoor therapy for 37 men with low mood (mean [SD] PHQ‐9 score = 11.4 [5.0]; mean [SD] age = 44.1 [15.8] years). Over 6 weeks at the University of Newcastle participants received weekly 60‐min sessions delivered (i) while walking along a 4‐km route on campus or (ii) indoors in a psychology clinic, delivered by provisional psychologists using non‐directive supportive counselling. Outcomes included validated measures of depression, anxiety, stress and overall psychological distress, male‐type depression, mental well‐being, behavioural activation and therapeutic alliance. At post‐intervention, all pre‐registered feasibility benchmarks were exceeded including recruitment capability, retention (89%), average attendance (walk‐and‐talk: 91%, indoor: 89%), proportion of sessions delivered in intended setting (walk‐and‐talk: 100%, indoor: 98%) and overall perceived acceptability of the therapy (walk‐and‐talk: 4.4/5, indoor: 4.2/5, where 1 = poor and 5 = excellent). Linear mixed model analysis demonstrated both groups achieved similar improvements in depressive symptoms (d = −0.02), but the walk‐and‐talk group reported greater improvements in overall psychological distress (d = −0.5), anxiety (d = −0.4) and stress (d = −0.7). In contrast, male‐type depression improved more in the conventional indoor group (d = 0.6). Other outcomes were comparable between groups. Results indicate that walk‐and‐talk therapy may be acceptable and effective for men with depression. A powered trial to interrogate these effects and identify moderators of effectiveness is warranted.

Trial Registration: Australian New Zealand Clinical Trials Registry number: ACTRN12622001318774.

Keywords: males, outdoor therapy, physical activity, psychotherapy, randomised trial

Summary.

  • While psychotherapy is effective for treating depression, men are less likely than women to participate and more likely to drop out early.

  • Delivering sessions outdoors may lead to improved engagement and outcomes in men for several reasons (e.g., shoulder‐to‐shoulder orientation, less direct eye contact, indirect benefits of physical activity and nature).

  • In this pilot study, we found walk‐and‐talk therapy was both feasible and effective for engaging men in psychotherapy.

1. Introduction

Depression is a mental illness characterised by persistent low mood and feelings of sadness (American Psychiatric Association 2022). It affects approximately 280 million people around the world, including more than 109 million men (Institute for Health Metrics and Evaluation 2021). In Australia, one in eight men experience depression at some stage of their lives (Australian Bureau of Statistics [ABS] 2022a). However, this is likely an underestimate due to low rates of help seeking. In 2020–2021, only 36% of Australian men in distress sought professional help, compared to 51% women (ABS 2022a). This may partially explain the paradox where Australian men are half as likely to be diagnosed with depression as women, but three times more likely to die by suicide (the largest and third largest cause of death in men aged 15–44 and 45–65, respectively) (ABS 2022b). Currently, the standard of care for treating depression is psychotherapy, henceforth referred to as therapy (Cuijpers, Stringaris, and Wolpert 2020). While therapy dropout does not appear to be moderated by sex in clinical research trials (Swift and Greenberg 2012), a survey of 2000 Australian men attending therapy in the community reported very high rates of dropout (Seidler et al. 2021). Overall, one in two participants reported that they had ceased treatment prematurely. Of this group, one in four withdrew after a single session. Notably, one of the most common reasons for dropout was ‘it didn't feel right’ (Seidler et al. 2021). Given the dominant form of masculinity in Australia expects men to display strength, stoicism and complete emotional control (Flood 2020), it is somewhat unsurprising many find it hard to share their emotions and vulnerabilities with someone they have just met, face‐to‐face in a formal and unfamiliar environment, for repeated sessions over time. Given poor therapy experiences deter men from future help seeking (Seidler et al. 2020), urgent action is needed to better support those who do seek help.

Recently, the American Psychological Association released their first set of guidelines for working with men and boys, including changing the structure of interventions to be congruent with male socialisation and values (American Psychological Association 2018). However, little experimental evidence is available to guide how this should be conducted. For example, a scoping review of psychotherapy trials for depression over the past decade did not identify a single study targeting men (compared to 20 studies [18%] that targeted women) (Knox et al. 2022). Where it has been examined, treatment outcomes do not appear to be moderated by sex (Swift and Greenberg 2012). However, to build actionable and evidence‐based strategies to support men, it is still important to target men in rigorous clinical trials.

In contrast to conventional therapy, which almost exclusively takes place indoors, outdoor ‘walk‐and‐talk’ therapy has potential to engage men for several reasons (Doucette 2004). First, the shoulder‐to‐shoulder orientation naturally reduces eye contact, which may feel less formal and interrogative when discussing sensitive topics (Robertson et al. 2018). Second, taking sessions outdoors creates a shared ownership of the therapeutic space and may de‐emphasise the inherent power imbalance between clients and therapists (Cooley et al. 2020). Third, clients in walk‐and‐talk therapy may benefit from the known anti‐depressant effects of physical activity (Rebar et al. 2015) and exposure to nature (where the sessions are conducted in a natural setting) (Twohig‐Bennett and Jones 2018). Finally, leveraging on the success of men's sheds, walk‐and‐talk therapy may strengthen the therapeutic alliance by facilitating action empathy (i.e., men's tendency to create authentic connections by engaging in a shared activity) (Englar‐Carlson 2006). These factors suggest that walk‐and‐talk therapy may represent a well‐rounded approach to address depression in a way that caters to men's unique needs and preferences (Seidler et al. 2018).

In a recent meta‐synthesis of 38 qualitative studies, Cooley and colleagues concluded that outdoor therapy was highly beneficial and valued by both practitioners (n = 322) and service end‐users (n = 163) (Cooley et al. 2020). Importantly, while some barriers were reported (e.g., privacy concerns, poor weather), clinicians generally found these could be managed with adequate pre‐screening and planning, even among higher risk inpatient groups (Cooley et al. 2020). Supporting these qualitative insights, researchers have begun to study the efficacy of walk‐and‐talk therapy in experimental trials (Korpela, Stengård, and Jussila 2016; Koziel et al. 2022).

However, to our knowledge, researchers have yet to employ a randomised design to specifically investigate whether taking therapy outdoors in combination with physical activity has an additive benefit on mental health outcomes beyond those delivered by conventional indoor therapy alone. Further, we are unaware of any studies examining the benefits of walk‐and‐talk therapy for men.

For these reasons, we conducted the current pilot study to investigate the feasibility, acceptability and preliminary efficacy of walk‐and‐talk psychotherapy compared to conventional indoor therapy for managing depressive symptoms in Australian men.

2. Methods

2.1. Study Design

This was a 7‐week randomised pilot study. The study was approved by the University of Newcastle Human Research Ethics Committee. Participants were randomly allocated to either conventional indoor therapy (sitting down indoors) or walk‐and‐talk therapy (walking outdoors). At the end of the study, participants received a $20 voucher as a gratuity for their involvement in the trial.

2.2. Participants

Participants were recruited from the Hunter region of New South Wales, Australia, over two weeks in October 2022. As this was a feasibility study, a formal sample size calculation was not performed, though a recruitment goal of 30 participants was selected to align with previous pilot study guidelines and to provide stable estimates of retention, satisfaction and preliminary efficacy (Eldridge et al. 2016). Recruitment strategies included paid Facebook advertising, emails to a registry of men who were interested in hearing about mental health research opportunities and local media exposure (e.g., radio interviews).

Participants were eligible if they (i) identified as a man, (ii) were aged 18–70 years and (iii) reported at least mild depressive symptoms in the previous two weeks (represented by a score ≥ 5 on the validated 9‐item Patient Health Questionnaire [PHQ‐9] depression screener) (Kroenke, Spitzer, and Williams 2001). While a PHQ‐9 score ≥ 10 (moderate symptoms or above) has greater sensitivity for detecting Major Depression, we applied the lower threshold given existing diagnostic scales often underestimate men's experiences of depression (Martin, Neighbors, and Griffith 2013). Participants required a medical clearance from their general practitioner if they were at a higher risk of experiencing an adverse event due to exercise, based on their responses to Exercise and Sport Science Australia's Adult Pre‐Exercise Screening System questionnaire (Exercise and Sport Science Australia 2019). All participants provided written, informed consent prior to enrolment.

2.3. Randomisation

Participants were randomised once all had completed baseline assessments and booked in for a recurring weekly session time. The study chief investigator randomly allocated men to the conditions using a randomisation list generated by an independent research assistant using the online Sealed Envelope randomisation tool (Sealed Envelope Ltd 2022). Aside from this task, the research assistant was not otherwise involved in the trial. To ensure all psychologists received clients from both groups, but no more than three walk‐and‐talk sessions on their typical workday of five sessions, the schedule was stratified by psychologist and blocked in groups of four. To conceal allocations, study arm names were replaced with numeric codes on the randomisation list, which were only revealed to the chief investigator once randomisation was complete. During the randomisation process, participants were allocated the next available place on the list in chronological order based on their first scheduled session.

2.4. Interventions

Participants received either conventional indoor therapy or walk‐and‐talk therapy for the duration of the study. Both interventions consisted of six 1‐h individual non‐directive supportive therapy sessions over a period of 6 weeks delivered by three postgraduate provisional psychologists who were completing a clinical placement as part of their postgraduate clinical psychology training. This approach has been defined as ‘an unstructured therapy without specific psychological techniques other than those belonging to the basic interpersonal skills of the therapist, such as reflection, empathic listening, encouragement, and helping people to explore and express their experiences and emotions’ (Cuijpers et al. 2012). This therapy approach was selected for the current study because (i) it could be feasibly delivered in both indoor and outdoor environments, (ii) the provisional psychologists had all demonstrated competency with this approach during their training and (iii) it is effective for treating depression (Cuijpers et al. 2012). Prior to working with participants, members of the research team (a.d., S.H. and M.Y.) delivered a training session for the therapists, involving walking the therapy route, contingency planning, strategies for maintaining safety and confidentiality and discussion of the proposed therapy approach. All therapists delivered therapy in both study arms. Participants had the same therapist for the duration of the study. There was no cost to participants for the sessions.

By ensuring that men in both study arms received treatment from the same therapists using the same treatment modality, our major experimental manipulation related solely to the format of the therapy. In the conventional indoor therapy arm, sessions occurred at the University Psychology Clinic, a public facing clinic that included four consultation rooms. In contrast, the walk‐and‐talk therapy sessions began outside the clinic and then occurred while walking along an approximately 4‐km predetermined route on the University campus. Therapists and participants in the walk‐and‐talk group were provided with umbrellas, sunscreen and insect repellent during the sessions. The route included both built elements (e.g., walking along paved footpaths and near buildings) and a 20‐min bushwalk component in a biodiverse nature reserve through the University wetlands (see Supporting Information).

2.5. Safety Processes

To support participant safety, all emails to the study email account received an automated reply with contact information for 24‐h mental health support services and a confirmation we would get in touch within 72‐h. The information statement also contained contact details for the research team and participants were encouraged to reach out if they experienced any concerns with their mood or otherwise during the trial. During recruitment and screening, a provisionally registered psychologist (a.d.) conducted suicide risk assessments when clinically indicated. Men were also contacted at post‐intervention if their depression, anxiety or stress scores had increased into a more severe category compared to their baseline measurement. If the score had increased by a single severity category, we contacted them and provided additional support and referrals if necessary.

2.6. Measures

2.6.1. Feasibility Outcomes

To determine study feasibility, we set a priori benchmarks for recruitment (30 participants recruited), setting fidelity (≥ 50% sessions conducted in the intended setting on average, assessed separately by group), attendance (≥ 50% of sessions attended on average per condition), retention (≥ 80% of participants retained at post‐intervention) and programme satisfaction (mean satisfaction with intervention at least 4/5 on a single item scale ranging from 1 [poor] to 5 [excellent], per condition). Attendance and setting fidelity measures were tracked in an online log that therapists completed at the end of each session.

2.6.2. Preliminary Efficacy Outcomes

Once enrolled in the study, all participants completed a pre‐intervention survey with mental health measures approximately 1 week before their first therapy session (see Table 1).

TABLE 1.

Preliminary efficacy measures.

Measure Reference Items Example item Anchors Cronbach's alpha (α)
Depression, Anxiety, and Stress Scale (DASS‐21) Lovibond and Lovibond (1995) 21 In the past week, ‘I felt downhearted and blue’ Did not apply to me (0)–Applied to me very much (3)

Overall: 0.91

Depression subscale: 0.79

Anxiety subscale: 0.87

Stress subscale: 0.84
Masculine Depression Risk Scale (MDRS‐22) Rice et al. (2013) 7 Over the last month, ‘I needed alcohol to help me unwind’ Not at all (0)–Almost always (7) 0.81
Warwick‐Edinburgh Mental Well‐Being Scale (WEMWBS) Tennant et al. (2007) 14 Over the last 2 weeks, ‘I've been feeling confident’ Never (1)–Always (5) 0.77
Acceptance and Action Questionnaire (AAQ‐II) Bond et al. (2011) 7 ‘Worries get in the way of my success’ Never true (1)–Always true (7) 0.84
Behavioural Activation for Depression–Short Form (BADS‐SF) Manos, Kanter, and Luo (2011) 9 Over the last week, ‘I was an active person and accomplished the goals I set out to do’ Not at all (0)–Completely (6) 0.75
Session Rating Scale (SRS) Duncan et al. (2003) 4 Relationship E.g., ‘I did not feel heard, understood, or respected’ (0)–‘I felt heard, understood, and respected’ (10) 0.95
Working Alliance Inventory–Short Form (WAI‐C) Tracey and Kokotovic (1989) 12 ‘I believe my therapist likes me’ Never (1)–Always (7) 0.93
Adapted Restoration Outcome Scale (ROS‐6) Korpela et al. (2008) 6 ‘When I was participating in my therapy session, my concentration and alertness clearly increased’ Not at all (1)–Completely (7) 0.92
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2.6.3. Demographics

Demographic information included age, self‐reported employment status, education level, country of birth, ethnicity and marital status. Socio‐economic status was estimated by cross‐referencing participants' postcodes with the Index of Relative Socio‐economic Advantage and Disadvantage (IRSAD) from the Australian Government's Socio‐Economic Indexes for Areas (SEIFA) tool (ABS 2023). Using census data, each postcode is assigned a decile score from 1 (most disadvantaged 10% of suburbs) to 10 (most advantaged 10% of suburbs). In the current study, decile scores were grouped into three categories: low (1–3), medium (4–7) and high (8–10).

2.6.4. Adverse Events

Adverse event data were captured by therapists in the post‐session online logs. After documenting attendance, the therapists were asked the following question (which was created for the current study): ‘Did you observe any “adverse events,” “side effects” or “unwanted events” during the session today? These include all negative events that were caused (or probably caused) by the treatment and include physical health issues (e.g., sprained ankle), mental health issues (e.g., deterioration of symptoms), and interpersonal issues (e.g., ruptures to therapeutic alliance).’ If they reported yes, they were prompted to provide details.

2.6.5. Treatment Preference

Prior to randomisation, participants were asked if they would prefer to be randomly allocated into the walk‐and‐talk therapy arm or the conventional therapy condition arm. They were informed that their response would have no influence on the actual randomisation process.

2.6.6. Session Step Count

To track their step counts during the sessions, walk‐and‐talk participants wore Yamax SW200 pedometers on their right hip (usually on their belt) in line with their knee. These data were recorded by the therapists at the end of the session.

2.7. Data Analysis

Descriptive analyses (i.e., percentage and frequency counts) were conducted to assess overall recruitment and retention. Independent samples t‐tests were used to compare the groups for setting fidelity, attendance, satisfaction and for preliminary efficacy measures collected at post‐intervention only (i.e., therapeutic alliance, perceived mental restoration). For preliminary intervention efficacy measures, linear mixed models were used to investigate group‐by‐time effects and effect sizes calculated using Cohen's d. Effect sizes were interpreted as small (d = 0.2), medium (d = 0.5) or large (d = 0.8) (Cohen 1988).

3. Results

3.1. Feasibility Outcomes

3.1.1. Recruitment Capability

During a 2‐week recruitment period, 47 men expressed interest in the study by completing the screener survey (Figure 1). Of these, 81% (n = 39) met the eligibility criteria. Most of these participants were recruited via Facebook advertising (65%, n = 24), an email to a database of men who were interested in hearing about research opportunities (14%, n = 5) or radio advertising (8%, n = 3). Of those who were eligible, 37 completed the baseline assessment and were randomised, which exceeded the recruitment target of 30 participants.

FIGURE 1.

FIGURE 1

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Participant flowchart.

As seen in Table 2, participants' mean ± SD age was 44.1 ± 15.8 years. Based on PHQ‐9 cut‐off scores, 46% of men reported mild depressive symptoms compared to 54% in the moderate‐to‐severe category. Overall, 49% of participants had a university degree, 89% were born in Australia, 70% lived in areas of low to middle socio‐economic status (SEIFA deciles 1–6) and 49% were married. Most men (87%) reported a pre‐randomisation preference for walk‐and‐talk therapy over conventional indoor therapy.

TABLE 2.

Participant characteristics.

Characteristic Conventional indoor (n = 17) Walk‐and‐talk (n = 20) Total (n = 37)
n % n % n %
PHQ‐9 depression category
Mild 9 53 8 40 17 46
Moderate‐to‐severe 8 47 12 60 20 54
Highest education level
High school only 5 29 5 25 10 27
Trade/certificate 2 12 7 35 9 24
University degree 10 59 8 40 18 49
Employed full‐time 7 41 9 45 16 43
Born in Australia 17 100 16 80 33 89
Indigenous identity
Aboriginal 1 6 0 0 1 3
Torres Strait Islander 0 0 0 0 0 0
Both 0 0 1 5 1 3
Married/de‐facto 7 41 11 55 18 49
Socio‐economic status a
Low 4 24 4 20 8 22
Middle 9 53 9 45 18 49
High 4 24 7 35 11 30
Age (mean, SD) 41.9 18.0 45.9 13.8 44.1 15.8
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a

Socio‐economic status by population decile for SEIFA Index of Relative Socio‐economic Advantage and Disadvantage (low = 1–3, medium = 4–7, high = 8–10).

Of note, while the groups were comparable on most outcomes at baseline, there were some differences between conditions such that participants in the walk‐and‐talk condition reported more stress (Cohen's d = −0.63) and higher overall psychological distress (Cohen's d = −0.31) than participants in the conventional condition (see Table S1). Alternatively, participants in the conventional therapy condition reported greater overall masculine depression symptoms at baseline (Cohen's d = 0.34).

3.1.2. Attendance and Retention

In total, participants in both conditions attended nearly the same number of sessions on average (approximately 90%; see Table 3). The attendance exceeded the feasibility benchmark of ≥ 50%. A total of 89% (n = 33) completed the post‐test assessments, which also exceeded the feasibility benchmark of ≥ 80%. While the difference in retention between groups was not statistically significant (χ 2 = 1.5, df = 1, p = 0.22), it is notable that the retention in the walk‐and‐talk condition (95%) was greater than observed in the conventional condition (82%).

TABLE 3.

Feasibility outcomes.

Outcome Metric Pre‐registered benchmark Pilot outcomes
Recruitment capability Number of participants randomised 30 men randomised 37 randomised
Attendance Proportion of sessions attended by participants Average session attendance ≥ 50%

Walk‐and‐talk: 91%

Indoor: 89%
Setting fidelity Proportion of sessions delivered in intended setting Average session setting fidelity ≥ 50%

Walk‐and‐talk: 100%

Indoor: 98%
Retention Proportion of randomised participants who complete post‐intervention questionnaire ≥ 80% retention 86% retained
Satisfaction Mean satisfaction with therapy (1 = poor, 5 = excellent) Mean score ≥ 4/5

Walk‐and‐talk: 4.4/5

Indoor: 4.2/5
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3.1.3. Fidelity of Intended Therapy Setting

Across the six therapy sessions, the setting fidelity benchmark (≥ 85%) was exceeded in both conditions. When the client attended the session, 100% of the walk‐and‐talk therapy sessions were delivered outdoors compared to 98% of indoor therapy sessions delivered indoors (one indoor session was conducted over the phone when the participant forgot the appointment).

3.1.4. Participant Satisfaction

Participants in both conditions considered the overall quality of the therapy experiences to be high. On a scale of 1 (poor) to 5 (excellent), the mean (SD) overall programme satisfaction score for conventional indoor therapy was 4.2 (1.3) and 4.4 (0.6) for walk‐and‐talk, which both exceeded the feasibility benchmark (≥ 4 out of 5).

3.2. Preliminary Efficacy Measures

3.2.1. DASS‐21 Outcomes (Depression, Anxiety, Stress and Overall Psychological Distress)

There was a small‐to‐medium group‐by‐time effect on overall psychological distress (d = −0.45) favouring walk‐and‐talk therapy, consisting of a medium‐to‐large impact on stress (d = −0.66) and small‐to‐medium impact on anxiety (d = −0.43) (see Table 4). There was no clear group‐by‐time effect on depression (d = −0.02), as both groups improved equally in this outcome. Within‐group changes indicated both groups decreased their baseline depressive symptoms by 36% from baseline to post‐intervention.

TABLE 4.

Mental health outcomes.

Mental health measures Group Baseline Post‐test Within‐group change Between‐group difference
M ± SE M ± SE M (95% CI) Cohen's d a M (95% CI) Cohen's d b
Overall Psychological Distress (DASS‐21) c Walk‐and‐talk 49.6 ± 4.8 29.7 ± 4.0 −19.9 (−27.0, −12.8) −0.93
Indoor 43.1 ± 5.2 30.5 ± 4.5 −12.6 (−20.7, −4.5) −0.59 −7.3 (−18.0, 3.5) −0.45
Depression subscale c Walk‐and‐talk 19.9 ± 1.8 12.6 ± 2.0 −7.1 (−11.4, −2.8) −0.90
Indoor 20.2 ± 2.0 13.1 ± 2.2 −7.3 (−11.0, −3.6) −0.87 −0.2 (−5.9, 5.4) −0.02
Anxiety subscale c Walk‐and‐talk 9.3 ± 2.0 4.8 ± 1.4 −4.5 (−6.8, −2.2) −0.51
Indoor 7.9 ± 2.1 5.6 ± 1.6 −2.2 (−4.8, 0.4) −0.26 −2.2 (−5.7, 1.2) −0.43
Stress subscale c Walk‐and‐talk 20.4 ± 2.0 12.4 ± 1.5 −8.0 (−11.2, −4.9) −0.92
Indoor 14.9 ± 2.1 11.6 ± 1.7 −3.3 (−6.9, 0.2) −0.38 −4.7 (−9.5, 0.1) −0.66
Mental Wellbeing d (WEMWBS) Walk‐and‐talk 37.9 ± 1.3 44.2 ± 1.8 6.3 (3.4, 9.2) 1.10
Indoor 38.2 ± 1.4 44.4 ± 2.1 6.1 (2.7, 9.5) 1.07 0.2 (−4.3, 4.7) 0.03
Masculine Depression c (MDRS‐22) Walk‐and‐talk 29.0 ± 3.5 23.4 ± 2.9 −5.6 (12.3, 1.2) −0.35
Indoor 34.4 ± 3.8 19.8 ± 3.3 −14.6 (−22.2, −7.0) −0.93 9.0 (−1.2, 19.2) 0.60
Psychological Flexibility c (AAQ‐II) Walk‐and‐talk 25.7 ± 1.9 22.3 ± 32.5 −3.4 (−6.8, −0.1) −0.41
Indoor 26.5 ± 2.0 22.1 ± 2.1 −4.4 (−8.3, −0.6) −0.53 1.0 (−4.1, 6.1) 0.14
Behavioural Activation d (BADS‐SF) Walk‐and‐talk 27.4 ± 2.1 34.9 ± 2.4 7.5 (2.8, 12.3) 0.81
Indoor 27.5 ± 2.3 33.8 ± 2.7 6.3 (0.8, 11.8) 0.68 1.2 (−6.1, 8.5) 0.11
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Abbreviations: AAQ‐II, Acceptance and Action Questionnaire–Version 2; BADS‐SF, Behavioral Activation for Depression Scale–Short Form; DASS‐21, Depression, Anxiety and Stress Scale–21 item version; MDRS‐22, Masculine Depression Risk Scale–22 item version; WEMWBS, Warwick Edinburgh Mental Wellbeing Scale.

a

Cohen's d = (post‐test − baseline)/SDbaseline.

b

Cohen's d = (Indoorchange − Walk‐and‐Talkchange)/Pooled SDchange.

c

Decrease represents an improvement.

d

Increase represents an improvement.

3.2.2. Additional Mental and Behavioural Outcomes

At post‐intervention, we observed a medium‐to large group‐by‐time effect for masculine depression favouring the conventional indoor group (d = 0.60), indicating that masculine depression improved more in the conventional indoor therapy group.

As seen in Table 4, we did not observe substantive group‐by‐time effects for mental wellbeing, psychological flexibility or behavioural activation (all d < 0.15). Both groups reported equivalent improvements in these outcomes.

3.2.3. Therapy‐Related Outcomes

As seen in Table 5, there were no clear between‐group differences in measures assessing the quality of the therapeutic alliance or the mental restoration participants experienced by attending therapy (all d < 0.20).

TABLE 5.

Therapy‐related outcomes.

Outcome Group Post‐intervention Between group difference
M ± SD M (95% CI) p Cohen's d
Therapeutic alliance
WAI‐C Walk‐and‐talk 6.8 ± 0.4
Indoor 6.8 ± 0.2 0.0 (−1.0, 0.9) 0.43 0.03
SRS Walk‐and‐talk 36.2 ± 3.8
Indoor 35.4 ± 5.6 −0.8 (−4.0, 2.4) 0.62 0.17
Mental restoration (ROS‐6) Walk‐and‐talk 4.9 ± 1.3
Indoor 4.7 ± 1.5 −0.3 (−1.3, 0.7) 0.30 0.19
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Abbreviations: ROS‐6, Restoration Outcome Scale–6‐item (adapted); SRS, Session Rating Scale (completed after each session and averaged for analysis); WAI‐C, Working Alliance Inventory–Short Form (completed once during the post‐test survey).

3.2.4. Physical Activity Data

After averaging each walk‐and‐talk participant's step count recordings across the six sessions, within‐session physical activity levels ranged from 1708 steps/session to 5177 steps/session. The overall mean across participants was 3994 steps/session (SD 683 steps), which approached the step cadence recommended for adults to achieve ‘moderate intensity’ physical activity (100 steps/min) (Slaght et al. 2017).

3.2.5. Adverse Events

Across all conventional indoor sessions delivered (n = 109), the therapists did not report any potential adverse events, side effects or unwanted events that were caused (or probably caused) by the intervention. For the walk‐and‐talk sessions (n = 109), the therapists noted three potential adverse events (2.7% of sessions affected). All were brief encounters that interrupted the flow of the session (e.g., brief awkwardness while another person was walking nearby during part of the session).

4. Discussion

This study examined the feasibility and preliminary efficacy of walk‐and‐talk therapy for men with low mood compared to conventional indoor therapy. The feasibility benchmarks of the pilot study were all exceeded including recruitment capability, attendance, setting fidelity, retention and satisfaction. A medium‐sized intervention effect was found for overall psychological distress that favoured the walk‐and‐talk therapy condition, driven by larger improvements in stress and anxiety (but not depression, which improved equally in both groups). In contrast, male‐type depressive symptoms improved more in the conventional therapy condition. The therapy setting did not have a clear impact on the therapeutic alliance, within‐session mental restoration or behavioural activation levels, with positive findings observed for both groups.

Given men are typically underrepresented in depression research (Knox et al. 2022), it is notable that we exceeded our recruitment benchmark for this study (n = 30 participants) in only two weeks. This may be related to the targeted ‘men‐only’ study design or the credibility associated with participating in a University research project, which have shown promise for recruiting men in other fields where most participants are women including weight loss trials (Hunt et al. 2014; Young et al. 2021) and parenting programs (Morgan, Collins, et al. 2019; Morgan, Young, et al. 2019). Given 87% of the men reported a pre‐randomisation preference for walk‐and‐talk therapy over conventional indoor therapy, they may also have been particularly attracted to this alternative approach. Indeed, we did identify higher overall retention in the walk‐and‐talk therapy condition though it was not statistically significant. Despite this, the attendance and retention rates in both groups were high. This result was somewhat unexpected given studies suggest men are at a higher risk of dropout from conventional indoor therapy (Seidler et al. 2021). To speculate, the higher‐than‐expected attendance may have occurred because the therapy was free, or because the men we recruited were somehow different to those that seek therapy in clinical practice. The men may also have continued attending through an altruistic desire to support the research project and advance men's health (Tallon et al. 2011).

Notably, mean satisfaction ratings for both walk‐and‐talk and conventional therapy were strong. This is important because therapists have voiced concerns that their clients may find walk‐and‐talk therapy unacceptable due to potential privacy implications. However, our findings align with recent studies indicating that walk‐and‐talk therapy can be a highly valued approach following adequate planning and communication to mitigate any potential risks (e.g., Cooley et al. 2020; Koziel et al. 2022).

Given the pilot nature of the study, all efficacy findings are considered preliminary and must be interpreted as such. However, the study did reveal some interesting lines of inquiry that would be valuable to explore in a powered trial. First, it appeared that improvements in depressive symptoms were comparable between the walk‐and‐talk and conventional indoor conditions. This finding suggests that the contextual elements of walk‐and‐talk therapy are less important than the therapy itself for treating depression. While previous studies have highlighted the benefits of walk‐and‐talk therapy for depression, we believe ours was the first to include a conventional therapy control arm to specifically investigate the additional value of taking sessions outdoors (Kim et al. 2009; Korpela, Stengård, and Jussila 2016; Kotera et al. 2021; Koziel et al. 2022). Nonetheless, this finding does suggest that walk‐and‐talk therapy may be at least as effective as conventional therapy for treating traditional, internalised symptoms of depression. Subject to further testing, this would provide clinicians with another evidence‐based option to discuss with men.

In a future trial, it will be important to further explore the preliminary impact on male‐type depressive symptoms (e.g., drug use, risky alcohol consumption and aggression), which appeared to improve more in the conventional indoor therapy group relative to the walk‐and‐talk group. It is difficult to put this finding into context as we are not aware of any studies exploring the impact of therapy setting on this outcome. The standard indoor environment may be more suitable for working through externalising depressive symptoms due to greater perceived privacy. The formality of the indoor setting may also emphasise the perceived seriousness of the conversations about these symptoms. However, without further research these explanations remain speculative.

In contrast to depression, the walk‐and‐talk arm reported greater improvements in stress and anxiety than the indoor group at post‐test. As a result, when the DASS‐21 subscales were combined into an overall indicator of psychological distress, we observed a medium‐sized benefit favouring walk‐and‐talk therapy. Recently, a systematic review reported that walking in natural environments was particularly effective for reducing anxiety, despite mixed overall findings for depression (Kotera et al. 2021). Researchers studying the mechanisms linking outdoor walking to mental health have described physiological benefits related to stress and anxiety (e.g., decreased heart rate) (Mayer et al. 2009; Olafsdottir et al. 2020; Roe and Aspinall 2011), which may be linked to phytoncides, an antibacterial property of trees that increases immune functioning (Li 2010). Further, while much of the research examining the mental health benefits of physical activity has focused on depression, a growing body of research also confirms its utility for managing other conditions including stress (Puterman et al. 2010) and anxiety (McDowell et al. 2019).

Men in the walk‐and‐talk condition walked almost 4000 steps on average during their session, which were likely gained at a moderate pace for ~50 min. This dose may be sufficient to yield important physical and mental health benefits (Warburton, Nicol, and Bredin 2006), particularly if sustained beyond the therapy intervention period. Aside from this, we did not identify other potential mediation candidates to explain why the walk‐and‐talk group reported greater improvements in overall distress. While other studies have investigated the relation between nature connection and decreased stress and anxiety (Martyn and Brymer 2016; Sonntag‐Öström et al. 2015; Takayama, Morikawa, and Bielinis 2019), our results did not indicate significant differences between groups on the perceived restorative impact of the therapy setting. The restorative effects of nature may require attention to be intentionally directed at the natural elements, whereas men engaged in therapy sessions may have focused inwards on their own thoughts and emotions. Indeed, to standardise the interventions the therapists were advised to avoid incorporating the natural surroundings into the therapy session unless raised by the client.

To our knowledge, this was the first study to use a randomised controlled trial design to examine the acceptability and preliminary efficacy of walk‐and‐talk therapy compared to conventional indoor therapy, in men or otherwise. Other strengths include the use of validated measures to assess domains of physical and mental health, use of a therapeutic approach that was equally feasible for delivery in both contexts and incorporation of linear mixed models that ensured that the analyses were in line with the intention‐to‐treat principle (i.e., all recruited participants were represented in the data). In addition, 70% of men were recruited from areas of low to middle socio‐economic status.

Despite randomisation, there were some differences between conditions at baseline, with a medium effect size difference for stress and masculine depression. Given this, the intervention effects may be partially due to regression to the mean. Future studies should investigate moderators of intervention effectiveness (e.g., symptom severity, preference for indoor or walk‐and‐talk therapy, connection to nature and physical activity). Additional limitations were the brief therapy timeframe, which occurred in late spring/early summer and overlapped with a period of reasonably pleasant weather when the University campus was relatively quiet. Future studies would benefit by conducting waves of therapy across the different seasons and during busier periods to give fuller insights about the acceptability of this approach. This study examined only the comparison between walking outdoors and sitting indoors and did not investigate other potential combinations of these variables (e.g., walking indoors, sitting outdoors). Given multiple variables changed between the conditions (e.g., physical activity, exposure to nature, client‐therapist physical orientation), it is difficult to pinpoint which elements were the most important to explain any differences, but this is a rich area for future research to address. It is also important for future studies to increase the representation of Aboriginal and Torres Strait Islander participants given they have reported a preference for informal therapy settings, including outdoor walking, in previous research (Bennett‐Levy et al. 2014). The walk‐and‐talk approach also aligns with many aspects of the Aboriginal Social and Emotional Wellbeing Model including connections to mind and emotions, body and country (Gee et al. 2014).

5. Conclusions

This study found that walk‐and‐talk therapy was a feasible approach to engage men with low mood in therapy and improve their mental health. While improvements in several outcomes (including depression) were comparable between study arms, walk‐and‐talk therapy sessions appeared to generate a greater overall reduction in psychological distress. However, this finding remains subject to further exploration and replication in a larger trial. While men have been historically underrepresented in depression treatment research, this pilot study suggests they are eager and willing to participate in mental health studies that specifically target men and have the potential to lead to meaningful improvement in men's mental health.

Ethics Statement

This study was approved by the University of Newcastle Human Research Ethics Committee (Approval number H‐2022‐0276).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1. Baseline differences between conditions.

CPP-32-e70035-s002.docx (24KB, docx)

Figure S1. Example photographs of the built environment component of the walking route.

CPP-32-e70035-s003.pdf (4.2MB, pdf)

Figure S2. Example photographs of the bushwalk component of the walking route.

CPP-32-e70035-s001.pdf (5.5MB, pdf)

Acknowledgements

The authors would like to acknowledge the provisional psychologists who delivered the sessions. Thank you to Sonja Pohlman who facilitated the clinical placements, Ruby Hooke for providing therapist supervision, and Kira Mahoney and Dean Neighbour for their administrative support. Finally, we would like to sincerely thank the participants for their valued contribution to the study. Open access publishing facilitated by The University of Newcastle, as part of the Wiley ‐ The University of Newcastle agreement via the Council of Australian University Librarians.

Funding: This study was funded by an Internal University of Newcastle Cross–College Support Grant (2022).

Contributor Information

Andrea Dickmeyer, Email: andi.dickmeyer@uon.edu.au.

Myles D. Young, Email: myles.young@newcastle.edu.au.

Data Availability Statement

The quantitative data used to support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Table S1. Baseline differences between conditions.

CPP-32-e70035-s002.docx (24KB, docx)

Figure S1. Example photographs of the built environment component of the walking route.

CPP-32-e70035-s003.pdf (4.2MB, pdf)

Figure S2. Example photographs of the bushwalk component of the walking route.

CPP-32-e70035-s001.pdf (5.5MB, pdf)

Data Availability Statement

The quantitative data used to support the findings of this study are available from the corresponding author upon reasonable request.

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