Biophilia (Wilson) as guiding theory

1. Introduction

Version followed: the biophilia hypothesis as E. O. Wilson named it (Biophilia: The Human Bond to Other Species, Harvard University Press, 1984) and as Stephen R. Kellert and Wilson developed it (The Biophilia Hypothesis, Island Press, 1993), operationalised through Kellert's nine values of nature; applied through Kellert and Calabrese's The Practice of Biophilic Design (2015) and the University of Derby "pathways to nature connection" (Lumber, Richardson and Sheffield, 2017). The mechanisms clinicians usually cite alongside it are Kaplan's attention restoration theory (ART) and Ulrich's stress-reduction work. [source: Kirkus review of Wilson 1984; CARTA bibliography entry for Kellert and Wilson 1993; Kellert and Calabrese 2015; Lumber et al. 2017]

Biophilia is a theory, not a therapy. Wilson used the word for an innate, genetically based human attraction to living things, as distinct from inorganic matter [source: Kirkus review]. Kellert and Wilson's 1993 volume gathered scientists to refine and test the idea from psychological, biological, cultural, symbolic and aesthetic angles, weighing evidence for and against it; it pairs biophilia with "biophobia" (readily learned fears of snakes and spiders) and suggests that environmental loss may affect psychological and spiritual well-being, not only material life [source: CARTA abstract of Kellert and Wilson 1993]. Kellert himself concluded that the biological tendencies are "weak" and that learning and experience strongly shape how people value nature [source: Rolston 1997 review of Kellert, The Value of Life]. The hypothesis is widely described as hard to test directly [source: University of Derby FutureLearn course, citing Kahn 1999; secondary].

Core idea of change, as used in therapy [synthesis]: if humans carry a weak, learning-dependent affinity for living things, then a client's well-being can be supported by deliberately restoring repeated, meaningful contact with nature, in their surroundings (biophilic design) and in their relationship with nature (nature connection). Kellert and Calabrese stress that benefit depends on repeated and sustained engagement and that isolated elements (a single plant or picture) rarely achieve much [source: Kellert and Calabrese 2015]. Lumber et al. found that contact, emotion, meaning, compassion and beauty, not knowledge or identification of species, predicted connection [source: Lumber et al. 2017].

Evidence status in one line: a systematic review and meta-analysis of structured nature-based outdoor activities for adults (50 studies, 16 RCTs) reported reduced depressive mood and anxiety and improved affect in the RCTs, with weaker evidence for physical health and moderate-to-high risk of bias outside the RCTs [source: Coventry et al. 2021]. These are evaluations of nature-based activities; they do not test biophilia itself.

What the psychotherapist does with it [synthesis]: uses biophilia as a guiding theory for assessment (the client's relationship with nature), formulation (depletion, stress, disconnection), the therapy setting, between-session activities, outdoor work where trained, and referral to nature-based programmes (e.g. green social prescribing). Related guides in this family cover specific practices (forest bathing, horticultural therapy, care farming, green social prescribing at 015, walk-and-talk, blue care at 022); cold-water immersion stays in Domain X 196.

2. Framework

No founder or body publishes phases, a session count or a format for "biophilia-guided therapy"; the theory supplies a rationale, not a protocol [uncertain: not verified]. The sequence below is a clinician's working structure built from the sources [synthesis].

Phase A - Assessment of the client's nature relationship. Goal: map how the client currently relates to nature (Kellert's nine values: utilitarian, naturalistic, ecologistic-scientific, aesthetic, symbolic, dominionistic, humanistic, moralistic, negativistic), their access, barriers, fears and safety factors. Move on when you have a shared picture and no unaddressed safety or access barrier. [source for values: Rolston 1997; FutureLearn course]
Phase B - Shared formulation and psychoeducation. Goal: connect the presenting problem (e.g. stress, mental fatigue, low mood, isolation) to nature contact using ART and stress-reduction ideas, presented as theory. Move on when the client finds the rationale credible enough to try something; if not, keep nature as an optional strand. [source: Chang et al. 2007 summarising Kaplan 1995; Townsend and Weerasuriya 2010]
Phase C - Setting and environment. Goal: make the therapy room and the client's home or work space more biophilic (direct experience, indirect experience, space and place). Runs alongside other phases. [source: Kellert and Calabrese 2015]
Phase D - Pathway activities. Goal: in-session and between-session activities built on contact, beauty, meaning, emotion and compassion, with reflection. Move on when the client is engaging regularly and reports some benefit. [source: Lumber et al. 2017]
Phase E - Consolidation into routine and community. Goal: repeated, sustained engagement; referral to community or structured programmes (link worker, gardening group, nature-based therapy). [source: Kellert and Calabrese 2015; NHS England green social prescribing; Coventry et al. 2021]
Phase F - Review. Goal: check against the client's own goals; drop what does not help.

Format: usually integrated into an existing therapy (CBT, behavioural activation, ACT, humanistic or systemic work) rather than delivered as a stand-alone course [synthesis]. For structured programmes, Coventry et al. report that the more effective programmes in their review ran for about 8 to 12 weeks; that is a programme-evaluation finding, not a prescription [source: Coventry et al. 2021].

3. Guiding principles

Theory, held lightly. Present biophilia as Wilson's and Kellert's hypothesis, neither fact nor fad. Practical meaning: say "one theory suggests" and let the client's experience decide. [source: CARTA abstract; Rolston 1997]
Weak tendency, shaped by learning. Kellert describes the tendency as weak and strongly shaped by experience. Practical meaning: expect wide individual and cultural differences; affinity can be cultivated, not assumed. [source: Rolston 1997]
Repeated and sustained engagement. Kellert and Calabrese's first principle. Practical meaning: favour small regular contact over occasional big outings. [source: Kellert and Calabrese 2015]
Integration over tokens. Isolated elements rarely work. Practical meaning: combine several features (light, plants, views, materials, place) and link them to the client's goals. [source: Kellert and Calabrese 2015]
Attachment to place. Biophilic design encourages emotional attachment to particular settings. Practical meaning: help the client find and return to "their" places. [source: Kellert and Calabrese 2015]
Relationship and responsibility. Positive contact is meant to build a wider sense of relationship with, and responsibility for, human and natural communities. Practical meaning: values-based caring actions are part of the work, not an add-on. [source: Kellert and Calabrese 2015]
Beyond knowing nature. Knowledge and identification activities did not predict connection; contact, emotion, meaning, compassion and beauty did. Practical meaning: favour feeling, noticing and reflecting over naming species. [source: Lumber et al. 2017]
Reflection, not just exposure. A nature walk with no set activities did not raise connection; a walk with pathway activities did. Practical meaning: build in a noticing task and a debrief. [source: Lumber et al. 2017]
Nearby nature counts. Pathway activities may work in urban settings, and restoration can come from views and small places. Practical meaning: start where the client lives. [source: Lumber et al. 2017; Chang et al. 2007 (extent can be small, e.g. a Japanese garden)]
Respect biophobia and negative experience. Negativistic responses (fear, aversion) are part of Kellert's typology. Practical meaning: assess fear, trauma and disgust before suggesting contact; never push. [source: Rolston 1997; synthesis on clinical handling]
Cultural humility. Kellert's work in Botswana led researchers to add a "theistic" value for views that attribute conscious life to natural phenomena. Practical meaning: ask about religious, spiritual and cultural relationships with land and living things; describe Indigenous relationships only as communities themselves publish them. [source: Rolston 1997; synthesis]
Equity of access. Access to green space is unequal and remote areas are visited less than local parks. Practical meaning: assess cost, transport, disability, safety and discrimination in public spaces. [source: NHS England green social prescribing; Townsend and Weerasuriya 2010]
Safety first outdoors. Weather, terrain, allergies, ticks, hydration and accessibility assessed qualitatively; follow the published safety guidance of any programme used. Water is out of scope here (see 022 and Domain X 196). [synthesis]
Competence and role clarity. A therapist who also acts as a guide, gardener or group leader holds two roles; the multiple-relationships standard (APA Ethics Code Standard 3.05) applies where relevant; training, certification and insurance as the relevant certifying body states them; liability for outdoor sessions checked with the insurer [synthesis].
Client as the authority on meaning. What nature means to the client (solace, threat, faith, work, loss) leads the work. [synthesis]

4. Intervention inventory

The originating authors describe design attributes and nature-connection pathways, not clinical techniques. The items below translate those into therapist procedures; the content of each design attribute or pathway is sourced, while the clinical steps and wording are [synthesis] unless marked otherwise.

4.1 Nature-relationship history (values map)

Purpose / when: Early assessment, or whenever nature comes up. Gives a picture of how the client relates to nature, using Kellert's nine values as an interview frame. [source for values: Rolston 1997; FutureLearn course; clinical use synthesis]
Steps:
1. Ask for one or two nature memories from childhood and now (places, animals, plants, weather, seasons).
2. Listen for the values: use (utilitarian), pleasure in contact (naturalistic), curiosity and study (ecologistic-scientific), beauty (aesthetic), story and metaphor (symbolic), challenge and mastery (dominionistic), bonds with individual creatures (humanistic), ethical concern (moralistic), fear or aversion (negativistic); and religious or spiritual relationships (the "theistic" value added in Botswana research).
3. Note current contact: how often, where, alone or with others, what stops them.
4. Summarise the client's profile back in plain words and ask what fits.
5. If you want a standardised measure, the Nature Relatedness scale was used by Lumber et al.; administer only a licensed or published version and do not improvise items. [source: Lumber et al. 2017]
Example language (illustrative): "Tell me about a place outdoors, or an animal or plant, that has mattered to you. What was it like to be there?"
Watch for: Flat or absent responses (may reflect lack of access, not lack of interest); strong negativistic content (go to 4.2); grief for lost places or animals. Working: the client can name at least one source of pleasure, meaning or care in nature.

4.2 Screening for fear, trauma, safety and access

Purpose / when: Before any outdoor or contact-based task. Biophobia and negative experiences are expected parts of the human-nature relationship. [source: CARTA abstract; Rolston 1997; screening steps synthesis]
Steps:
1. Ask about fears and phobias (insects, spiders, snakes, dogs, open spaces, woods at dusk, heights), allergies (pollen, stings, plants), and any trauma linked to outdoor places.
2. Ask about physical health and mobility, sensory needs, medications affecting heat or sun tolerance, and pregnancy, and advise the client to check with their physician before a new outdoor programme when relevant [synthesis].
3. Ask about safety and belonging in public green space (harassment, racism, homophobia, being visible, lone-worker risks).
4. Ask about practical barriers: transport, cost, caring duties, time, weather clothing.
5. Record what is excluded and what is possible; route specific phobias to standard exposure-based treatment rather than "nature exposure".
Example language (illustrative): "Some people find being outdoors unsafe or frightening, for good reasons. Is there anything about parks, woods or animals that you'd want me to know before we go further?"
Watch for: Shame about fear; dissociation when describing a place; unrealistic plans that ignore barriers. Working: the client chooses options they feel safe with.

4.3 Psychoeducation: biophilia, attention restoration and stress recovery

Purpose / when: After assessment, to offer a rationale the client can accept or reject.
Content (sourced): Biophilia is Wilson's hypothesis of an innate attraction to living things [source: Kirkus review]; Kellert sees it as weak and shaped by experience [source: Rolston 1997]. ART (Kaplan 1995) holds that directed attention fatigues and that environments engaging effortless attention help it recover; restorative settings offer being away, extent, fascination (including soft fascination such as sunsets and flowing water) and compatibility [source: Chang et al. 2007]. Ulrich's work is cited for the view that natural settings help people cope with stress and recover from illness; his 1984 hospital study reported shorter stays and fewer strong painkillers for surgical patients with a tree view than with a brick-wall view [source: Townsend and Weerasuriya 2010; Landscape Performance Series summary of Ulrich 1984].
Steps: (1) Link the theory to the client's own words ("drained", "wired"). (2) Give one or two sentences per idea, labelled as theory. (3) Ask whether it matches their experience. (4) Agree a small test.
Example language (illustrative): "There's a theory that people have a built-in, if fairly weak, pull towards living things, and that time with nature can let the kind of effortful attention you use at work rest. We don't have to take that on trust - we can test it in your week."
Watch for: The client hearing it as "just go for a walk" or as dismissal of their distress. Working: the client proposes their own experiment.

4.4 Shared formulation of depletion and disconnection

Purpose / when: When stress, mental fatigue, low mood or isolation are central. [synthesis]
Steps:
1. Map a typical day: demands on directed attention, stress peaks, indoor hours, screen time.
2. Identify where any nature contact happens now (commute, window, garden, pet).
3. Draw a simple loop with the client: demand, depletion, withdrawal from restorative activities, more depletion.
4. Mark points where nature contact could interrupt the loop.
Example language (illustrative): "It looks as if the more drained you are, the less you do the things that used to top you up, like the allotment. Shall we see where that loop could be broken?"
Watch for: Over-attributing problems to "nature deficit"; missing depression, trauma or medical causes. Working: the formulation feels accurate to the client and points to a next step.

4.5 Biophilic audit of the therapy room

Purpose / when: Setting up or reviewing your own practice space. Draws on Kellert and Calabrese's three kinds of experience. [source: Kellert and Calabrese 2015]
Steps:
1. Direct experience: natural light, fresh air, living plants, a view of trees or sky; check client allergies before adding plants or flowers.
2. Indirect experience: images of nature, natural materials (wood, stone, wool), natural colours, naturalistic shapes.
3. Space and place: seating that gives prospect (a view out) and refuge (a protected back), organised rather than cluttered complexity, an easy-to-read route in and out.
4. Integrate several features rather than one token object; review with clients' feedback.
Example language (illustrative): "I've arranged the chairs so you can see the window but have the wall behind you. Tell me if a different seat would feel better."
Watch for: Sensory overload, allergies, plants or images that carry personal or cultural meanings for a client. Working: clients report the room as calm and comfortable. [synthesis]

4.6 Home and work environment audit (between-session task)

Purpose / when: Clients who spend most time indoors, are housebound, or are recovering from illness. [source for attributes: Kellert and Calabrese 2015; task synthesis]
Steps:
1. Give the client the three categories in your own words (living things and natural elements; images and materials; how the space feels).
2. Ask them to notice, over a week, where these are present or missing.
3. Choose one or two changes that are cheap and reversible (moving a chair to a window, a plant, opening a window, a nature picture).
4. Review what changed in mood, attention or comfort.
Example language (illustrative): "Before we change anything, just notice this week where in your flat you feel most settled, and what's there - light, a view, a plant, anything."
Watch for: Cost, landlord limits, a home that is unsafe, and plants toxic to pets or children (check before buying). Working: the client sustains the change and links it to a felt difference.

4.7 Window and view work

Purpose / when: Inpatients, housebound or less mobile clients, long work days at a desk; draws on Ulrich's view study and ART's point that restorative scenes can be viewed. [source: Landscape Performance Series summary of Ulrich 1984; Chang et al. 2007; Townsend and Weerasuriya 2010]
Steps: (1) Identify any view of trees, sky, water or greenery. (2) Agree short pauses to look out with no task. (3) Where no view exists, use natural images or nearby planting. (4) Ask what the client noticed and how they felt after.
Example language (illustrative): "Next time you finish a call, would you be willing to look out at the tree for a moment before the next one - and just notice what happens?"
Watch for: Rumination during pauses (add a sensory noticing task, 4.8). Working: pauses become habitual and are described as restful.

4.8 Contact pathway: sensory noticing

Purpose / when: First active exercise; Lumber et al. define contact as engaging with nature through the senses, e.g. birdsong or the smell of wild flowers. [source: Lumber et al. 2017; Richardson 2017 blog]
Steps:
1. In session or outdoors, invite the client to notice, one sense at a time, what living things they can hear, see, smell and touch (only if safe and wanted).
2. Keep it short and unhurried; allow eyes open.
3. Debrief: what they noticed, what feelings came with it.
4. Set a between-session version in a place they already pass.
Example language (illustrative): "Let's take a moment by the window. What can you hear that's alive out there? ... And is there anything you can see moving?"
Watch for: Trauma-related hypervigilance outdoors; the exercise becoming a test they "fail". Working: the client notices more on repetition and reports pleasure or calm.

4.9 Beauty pathway: aesthetic noticing and creative response

Purpose / when: Clients drawn to art, photography or views; Lumber et al. describe noticing nature's shapes, colours and forms, e.g. visiting a place for the view, photographing or painting it. Beauty mediated the link between compassion activities and connection. [source: Lumber et al. 2017; Richardson 2017 blog]
Steps: (1) Invite the client to find one beautiful natural thing each day (a cloud, leaf, light on a wall). (2) Optionally photograph, sketch or describe it. (3) Bring examples to session and talk about what drew them. (4) Link to values or meaning (4.10).
Example language (illustrative): "This week, could you catch one thing in nature that strikes you as beautiful - however small - and bring a photo or a sentence about it?"
Watch for: Perfectionism about the photo or drawing; comparison with others. Working: the client starts noticing beauty without prompting.

4.10 Meaning pathway: natural symbols and metaphor

Purpose / when: Clients who think in images or stories, or are working on transitions and identity. Lumber et al. describe meaning as using natural symbolism to express ideas; Richardson's examples include reflecting on signs such as the first swallow of summer; Kellert's "symbolic" value covers nature in stories, myths and figures of speech. [source: Lumber et al. 2017; Richardson 2017 blog; Rolston 1997]
Steps:
1. Listen for nature metaphors the client already uses ("stuck in winter", "rooted", "storm").
2. Invite them to notice a seasonal sign or natural object that stands for something in their life now.
3. Ask them to write a few lines about what it means to them (in Lumber et al.'s walk, participants wrote down symbolic meanings they noticed).
4. Explore the meaning in session; let the client lead the interpretation.
Example language (illustrative): "You said you feel like a tree after a storm. What happens to a tree after a storm? Which part of that fits you?"
Watch for: Imposing your own symbolism; religious or cultural meanings you do not share (ask, do not interpret). Working: metaphors open new perspectives or hope.

4.11 Emotion pathway: speaking feelings about nature

Purpose / when: Any stage; Lumber et al. define emotion as feelings arising from engaging with nature, and in their walk participants talked about thoughts and feelings about what they saw. [source: Lumber et al. 2017; Richardson 2017 blog]
Steps: (1) After any nature contact, ask what the client felt, in the body and in words. (2) Reflect and validate, including sadness, envy or numbness. (3) Link feelings to the client's broader emotional life. (4) Encourage them to share such moments with someone close.
Example language (illustrative): "When you stood by the river, what did you feel? It's fine if it was mixed."
Watch for: Grief or loss surfacing (places that are gone, people associated with places); move at the client's pace. Working: wider emotional vocabulary and more felt connection.

4.12 Compassion pathway: caring actions for nature

Purpose / when: Clients with low purpose, guilt or powerlessness; Lumber et al. define compassion as extending the self to include nature and caring for other beings, e.g. ethical choices or concern for animal welfare; Kellert's moralistic value is ethical concern for nature; biophilic design aims at a wider sense of responsibility. [source: Lumber et al. 2017; Rolston 1997; Kellert and Calabrese 2015]
Steps:
1. Ask what in nature the client cares about.
2. Agree one small, doable caring act (feeding birds, a window box for pollinators, a litter pick, joining a conservation volunteer day).
3. Frame it as values-based action; link to behavioural activation if mood is low (Domain II 040).
4. Review how it felt and whether it fits their values.
Example language (illustrative): "You lit up talking about the hedgehogs. Is there one small thing you could do for them - or for any creature - this week?"
Watch for: Guilt, scrupulosity or eco-distress escalating (see 4.18); over-commitment. Working: the client reports purpose and continues without prompting.

4.13 Choosing restorative places (ART checklist)

Purpose / when: Clients with mental fatigue, burnout or poor concentration. Uses ART's four components from Kaplan (1995). [source: Chang et al. 2007]
Steps:
1. Brainstorm accessible places (park, garden, cemetery, canal path, a tree-lined street).
2. Rate each, with the client, on: being away (feels distant from usual demands); extent (enough to explore or feel immersed, can be small); fascination (holds attention without effort, e.g. moving water, leaves, clouds); compatibility (suits what they want and can do).
3. Pick the best fit and plan a first visit with safety and access in mind.
4. Review whether attention and mood shifted.
Example language (illustrative): "Which of these places feels furthest from your inbox, and has something that holds your eye without effort?"
Watch for: Places that are unsafe at certain times; "being away" turning into avoidance of necessary tasks. Working: the client reports feeling clearer or calmer after visits.

4.14 Place attachment and favourite-place work

Purpose / when: Grief, relocation, migration, or to anchor routine. Kellert and Calabrese list cultural and ecological attachment to place as an attribute and encourage emotional attachment to specific settings. [source: Kellert and Calabrese 2015]
Steps: (1) Ask about a place the client feels belongs to them, past or present. (2) Explore its sensory details and meanings. (3) If accessible, plan regular returns; if lost, explore grief and what of it can be carried into new places. (4) Help them adopt a new local place and watch it through the seasons.
Example language (illustrative): "Was there a place you felt at home outdoors before you moved here? ... Is there anywhere here that could slowly become yours?"
Watch for: Homesickness and migration grief; places linked to abuse. Working: a new place gains personal meaning.

4.15 Structured reflective nature walk (where the therapist works outdoors)

Purpose / when: Only where you are competent, insured and your setting permits outdoor sessions. Based on Lumber et al.'s finding that a walk with pathway activities increased connection while an unguided walk did not; their pathway walk combined attention to visual aesthetics, writing down symbolic meanings, talking about thoughts and feelings, and a compassion prompt. [source: Lumber et al. 2017; clinical framing synthesis]
Steps:
1. Agree in advance: route, accessibility, weather plan, what happens if you meet someone the client knows, how you will handle confidentiality in public, no touch, how to end or return indoors, and emergency contacts [synthesis].
2. During the walk, offer one pathway prompt at a time (beauty, meaning, emotion, compassion).
3. Leave silence; walk at the client's pace.
4. Close with a short debrief, outdoors or back indoors, and note it in the record.
5. Avoid water margins and remote routes in this format; see 022 and Domain X 196 for water.
Example language (illustrative): "If we see anyone you know, would you like us to just say we're out for a walk? And if you'd rather head back inside at any point, just say."
Watch for: Being overheard; weather, terrain, ticks, allergies, heat and hydration; the session becoming social chat; clients who feel watched. Working: richer reflection than indoors, without loss of safety or boundaries.

4.16 Building repeated, sustained contact into routine

Purpose / when: Consolidation; reflects the principle that biophilic benefit needs repeated and sustained engagement. [source: Kellert and Calabrese 2015; behavioural framing synthesis]
Steps:
1. Choose activities from 4.6-4.14 that the client enjoyed.
2. Attach them to existing routines (commute, lunch, school run) rather than adding big outings.
3. Plan for seasons and bad weather (indoor options: plants, views, images).
4. Use behavioural-activation monitoring if mood is low (Domain II 040). Do not set exercise durations, intensities or frequencies; physical-activity guidelines exist, and the client's physician or a qualified exercise professional advises on exercise.
Example language (illustrative): "What's one green moment that could ride along with something you already do every day?"
Watch for: All-or-nothing patterns; activities dropped in winter. Working: contact continues through setbacks.

4.17 Referral and collaboration: green social prescribing and nature-based programmes

Purpose / when: When the client wants structure, company or more than therapy can offer. In England, green social prescribing refers people to nature-based activities via a link worker who focuses on "what matters to the individual"; examples include walking-for-health schemes, community gardening and food growing; GPs, other practitioners and local agencies refer. Coventry et al. found gardening, green exercise and nature-based therapy most associated with mental-health benefit. [source: NHS England green social prescribing; Coventry et al. 2021]
Steps:
1. Prepare: discuss hopes, fears, access needs and what the client wants the programme to know.
2. Refer via the GP or link worker (England) or the local equivalent; with consent, share only what is needed.
3. Check the programme's own safety, safeguarding and accessibility guidance.
4. Debrief after the first sessions; integrate experiences into therapy; agree boundaries if you know the programme staff.
Example language (illustrative): "Would you like me to ask your GP about the link worker? They can find local groups - gardening, walking, conservation - and you choose."
Watch for: Social anxiety on joining a group; the programme being seen as a replacement for needed treatment. Working: attendance continues and the client reports connection. See 015 for green social prescribing in detail.

4.18 Working with ecological grief and distress

Purpose / when: When a client's strong moralistic or humanistic bond with nature brings grief, anger or anxiety about environmental loss; Kellert and Wilson's volume suggests environmental destruction may affect psychological and spiritual well-being. [source: CARTA abstract; clinical steps synthesis]
Steps: (1) Validate the distress as proportionate to real concern, not a symptom by default. (2) Assess functioning, sleep, hopelessness and risk using standard practice. (3) Balance grief with restorative contact (4.8-4.14) and meaningful action (4.12). (4) Consider peer groups such as those run by the Climate Psychology Alliance or the Good Grief Network, described as their organisers publish them [uncertain: not verified].
Example language (illustrative): "It makes sense to grieve what you love. Let's make room for that, and also look at what still nourishes you and what you can do."
Watch for: Hopelessness and suicidal thinking (follow your risk protocol; crisis lines: 988 in the US, Samaritans 116 123 in the UK and Ireland); compulsive checking of bad news. Working: distress becomes bearable and linked to action.

4.19 Review and consolidation

Purpose / when: At regular reviews and ending. [synthesis]
Steps: (1) Revisit the client's goals and the values map from 4.1. (2) Ask which activities helped and which did not, and keep only what helped. (3) If a standardised nature-connection measure was used at the start, repeat it. (4) Write a short relapse-prevention plan including nature contact for hard times.
Example language (illustrative): "Looking back over these months, which of the outdoor things actually made a difference for you - and which can we drop?"
Watch for: Attributing all gains to nature or none; losing the routine after ending. Working: the client has a plan they own.

5. Handling problems

The originating sources address design and connection, not clinical difficulties. Except where a source is cited, the guidance below is [synthesis].

"It's just going for a walk" / scepticism. Agree that it is a theory; offer a small experiment and let the data decide (4.3). Do not oversell; Kellert himself calls the tendency weak [source: Rolston 1997].
No felt benefit from simple exposure. Lumber et al. found an unguided nature walk did not raise connection and knowledge-only activities did not predict it [source: Lumber et al. 2017]. Add a pathway task and reflection (4.8-4.12) rather than more time outdoors; check whether depression, trauma or a medical problem needs its own treatment.
Fear, disgust or phobia (biophobia). Do not push contact. Start indoors with images and views (4.5-4.7); treat a specific phobia with standard exposure-based therapy with consent and contraindications reviewed, not with informal "nature exposure".
Outdoor places linked to trauma. Assess before suggesting outdoor work (4.2); choose neutral or indoor options; use grounding; return to trauma-focused treatment if triggers dominate.
Overwhelm or sensory overload. Shorten and simplify tasks, one sense at a time, eyes open, an exit plan; some people find busy parks more stressful than restorative.
Access barriers and inequity. Lack of nearby green space, cost, disability, caring duties and fear of harassment are real [source: NHS England green social prescribing on unequal access]. Work with what is reachable (window, street trees, a single plant, a cemetery or canal path) and use link workers or community programmes.
Non-adherence. Usually the task was too big, poorly timed or not valued. Shrink it, attach it to an existing routine (4.16), choose the pathway the client enjoys most, and plan for weather and seasons.
Seasonal and weather problems. Have indoor biophilic options ready; review clothing and safety; do not treat winter drop-off as failure.
Nature as avoidance. Restorative "being away" can become escape from necessary tasks or relationships. Name the function in the formulation and keep nature contact alongside, not instead of, approach goals.
Therapist enthusiasm and value imposition (rupture). A client may feel judged for not loving nature, or for using it differently (e.g. utilitarian or dominionistic values such as fishing or climbing). Repair by acknowledging it, returning to the client's own values map (4.1) and respecting cultural and religious relationships with nature.
Escalating ecological distress, guilt or hopelessness. Validate; assess risk with standard practice; balance grief with restorative contact and achievable action (4.18). Crisis lines: 988 (US), Samaritans 116 123 (UK and Ireland).
Physical safety outdoors. Weather, terrain, falls, ticks, stings and allergies, heat and sun, hydration and accessibility are assessed qualitatively and the programme's own published safety guidance followed. Water is out of scope: for open water see 022 (blue care) and Domain X 196 (cold-water immersion); open-water safety guidance comes from bodies such as the RNLI, the Outdoor Swimming Society and Swim England [uncertain: not verified].
Exercise, diet and medicines. Do not prescribe exercise amounts; refer to the physician or a qualified exercise professional. Never advise starting, stopping or changing a medicine.
Confidentiality and boundaries outdoors. Being seen, being overheard, chance meetings, travel together, touch and weather plans are agreed in advance and recorded (4.15). Offer an indoor alternative at every session.
Dual roles and competence. If you also run a nature group, garden project or guided walks, keep roles clear, avoid exploiting the relationship (APA Ethics Code Standard 3.05 on multiple relationships), hold the training required by any certifying body for that practice, and confirm that your professional insurance covers outdoor work.
Children and young people. Safeguarding, parental consent and the young person's assent, and the setting's policies apply to any outdoor activity; do not name or identify minors in records shared with programmes beyond what is needed.
Spiritual or religious meanings. Where nature carries religious meaning or a crisis of faith, explore it with the DSM-5-TR Cultural Formulation Interview and its supplementary module on spirituality, religion and moral traditions; where relevant, the DSM-5-TR "Religious or Spiritual Problem" can be coded Z65.8 (ICD-10-CM Z65.8 "Other specified problems related to psychosocial circumstances", which lists religious or spiritual problem under Includes) [source: ICD-10-CM Z65.8 (Unbound Medicine); DSM-5-TR wording uncertain: not verified]. Describe Indigenous relationships with land only as communities publish them.

Sources

Web sources:

Books and papers cited:

Wilson, E. O. (1984). Biophilia: The Human Bond to Other Species. Harvard University Press.
Kellert, S. R. and Wilson, E. O. (1993). The Biophilia Hypothesis. Island Press.
Kellert, S. R. The Value of Life: Biological Diversity and Human Society [year uncertain].
Kaplan, S. (1995). The restorative benefits of nature: toward an integrative framework [cited via Chang et al. 2007].
Ulrich, R. S. (1984). View through a window may influence recovery from surgery. Science 224, 224-225.
Kahn, P. H. (1999). The Human Relationship with Nature. MIT Press [cited via the Derby course; secondary].
APA Ethic al Principles of Psychologists and Code of Conduct, Standard 3.05.

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