Understanding a Novel Approach to Depression: Therapeutic Climbing

322 million people suffer from depression worldwide, making it the number one contributor to global disability [1]. Depression is typically treated with psychotherapy and/or medication, both of which are situationally effective [2]. Research has also pointed to the efficacy of exercise therapy in supplementing psychotherapy [3]. One novel exercise therapy is therapeutic climbing (TC). TC is a form of exercise therapy in which a group of participants engages in both rock climbing and non-climbing activities such as a reflection [4] or mindfulness activity [5] under therapist guidance. As in traditional climbing, therapy participants attempt to solve set climbs called “problems”, which vary in difficulty [5]. Bouldering and rope climbing are the two main disciplines of climbing, both of which have been used for TC. Each discipline uses problem-solving, planning, technique, and mental balance skills, with the primary difference being the duration of the exercise [6]. Research has shown that rock climbing may be superior to other exercise therapies [4], but future research needs to establish the reasoning behind its effectiveness. This review will explore the current state of research on therapeutic climbing.

Current Research on Therapeutic Climbing

Within psychotherapy, Cognitive Behavior Therapy (CBT) is the gold standard [7]. CBT is a type of talk therapy in which participants work directly with a therapist to analyze their thoughts and emotions. Research from Luttenberger et al. (2021) compared the impact of TC compared to CBT. 156 participants underwent a CBT, TC, or control (exercise) intervention over 10 weeks. In the TC group, participants began each session with a mindfulness exercise, bouldered, and then finished the session by discussing their experiences and performing body relaxation exercises. The researchers measured symptoms of depression using the Montgomery-Åsberg Depression Rating Scale (MADRS). TC reduced depression by an average of 4.63 points, compared to 3.46 points in the CBT group and 3.00 points in the control [5]. Thus, TC was just as effective as CBT and the effect was not due to exercise alone. Schwarz et al. (2019) similarly found that, after an 8-week intervention, depression scores improved by 7.21 points in the TC group and 2.14 in the non-therapy group (measured with the Beck Depression Inventory-II). They also discovered after 12 months the scores from the 97 participants did not shift significantly in either group [8]. This data shows the results of TC are long-lasting and not due to novelty. This research contributes to a growing body of literature that supports climbing as clinically effective at treating depression [5,9,10]. Given these results, TC can be considered a promising option for the treatment of depression.

Additional Benefits of Therapeutic Climbing

Climbing engages the entire body, promising both similar physiological benefits to other forms of exercise and different psychological benefits. TC improves many markers of psychological well-being relevant to treating depression [9,10]. One marker, self-efficacy, is well-researched in the treatment of depression and has been shown to improve with climbing, especially for beginners [9]. Jackman et al. (2017) defines self-efficacy as the belief in one’s ability to perform the necessary actions to complete a task. Self-efficacy, or belief in oneself, is a crucial factor for emotional well-being as these beliefs can directly and indirectly affect behavior. Self-efficacy can be developed in several ways, including personally overcoming challenges, which is particularly relevant to climbing. Climbing improves self-efficacy significantly more than exercise alone [5,9,10]. Thus, the development of self-efficacy appears to be linked with climbing. This makes sense as climbing provides many opportunities to overcome a range of challenges and lends itself to incremental progression. 

Thaller et al. (2022) also researched self-efficacy, but instead compared rope climbing and Nordic walking (NW) interventions on people with various mental health disorders. Nordic walking, or hiking with poles, is commonly recommended to patients with mental health disorders because it is accessible and a good alternative to a home exercise program. The outdoor setting also provides emotional and social benefits [12]. Previous research has demonstrated its positive effects on mental state and mood. In the Thaller et al. (2022) study, 21 participants each underwent one session of climbing, nordic walking, and a sedentary control. The climbing group also significantly affected self-efficacy whereas NW did not (as measured on the General Self-Efficacy Scale) [4]. Thus, self-efficacy could be a major contributor not only to the efficacy of TC, but also to explain why climbing is more effective than other therapies. Additionally, self-efficacy improved in both therapy and non-therapy interventions across both a 10-week intervention and a 1-day intervention, indicating that climbing itself can increase self-efficacy.

Concentration is also thought to be related to the treatment of depression [13]. Blakely et al. (2021) demonstrated that climbing invokes a large cognitive load, necessitating concentration. Climbers performed significantly worse at simultaneous cognitive tasks such as counting while climbing [14]]. Because climbing necessitates concentration, it helps participants focus on what they are doing in the moment. Similarly, models of “flow” and “clutch” mental states (complete task immersion and super performance under pressure) are common in climbing, emphasizing the present moment and a lack of thought about external things [15]. This evidence demonstrates that climbing invokes concentration, regardless of a therapeutic invention. However, concentration is necessary in other sports as well. Future research should compare how climbing develops concentration compared to other sports. 

Boudreau et al. also found different positive consequences associated with climbing including enjoyment, feelings of accomplishment, and confidence. Similarly, Thaller et al. found that climbing had a higher impact on positive affect (e.g. alert, determined, attentive, etc.) than the NW or the sedentary control group [4]. While in Thaller et al. 2022, none of the groups had significant differences in anxiety, Karg et al. (2020) found improvements in anxiety and body image. Climbing may also increase mindfulness [16], facilitate acute emotion regulation [17], and improve conscientiousness [18]. Climbing generally appears to be a positive experience for participants, however, climbing impacts so many mental states that it is difficult to determine which of these effects plays a role in the efficacy of TC. Future studies should work to differentiate them so that further targeted interventions can be developed. 

These positive experiences may also contribute to program adherence. In the study from Luttenberger et al. (2021) 84.7% of the participants in the TC group indicated that participation was pleasant compared to 47.9% in the CBT group. Participants’ willingness to engage in therapy could be a way in which TC is superior to CBT. Additionally, in the Kratzer et al. (2021) and Karg et al. (2020) studies, participants in the exercise group were less likely to get additional psychotherapy compared to the TC and CBT groups. 

Considerations for Implementing Therapeutic Climbing

Schwarzkopf et al. found the overall costs of TC to be high when compared to CBT, but the per-patient direct medical costs of a group therapy such as TC to be lower than CBT. Thus, the estimated probability of TC cost-efficacy is 50%. Researchers also note that “willingness to pay” thresholds for the treatment of depression are underdeveloped, and as such it is difficult to evaluate the cost-efficacy of TC accurately [19]. In general, data on the cost-efficacy of exercise therapy is still lacking [20]. However, considering the growing popularity of climbing, manufacturing costs associated with developing TC facilities are likely to go down. Additionally, the upfront costs of building such facilities would be the primary driver of costs, with upkeep expenses being relatively lower. There needs to be research on how different types of facilities impact the efficacy of TC, but TC could potentially be carried out using existing recreational rock climbing facilities. Additionally, group therapy intervention formats are less expensive when compared to traditional psychotherapy interventions [21]. Since TC is a type of group therapy, this should play a role in reducing costs.

Perception of injury risk could be detrimental to the effectiveness of TC. Research has not been done on how climbing being viewed as a dangerous sport may impact participation in TC. However, the injury rate for climbing activities is approximately 0.02 injuries per 1000 hours [22]. It seems fair to assume that an injury rate during TC would be similar. It also seems likely that TC injury rates could be lower than average due to proper education/preparation and therapist supervision. In the Luttenberger et al. (2021) study, participants climbed 1,386 bouldering hours with no resulting injuries. No other studies reported significant injuries either. Education on this point may be key to engaging as wide a population of participants as possible. However, a knowledgeable climbing therapist is important for the safe and effective implementation of TC. Training such therapists could be another major barrier to a more widespread implementation of TC.

There is also no research on the routine implementation of TC. There is, however, one study on expert opinions of TC. Frühauf et al. interviewed 30 experts (pedagogues, physicians, and psychologists) on their views of TC. Almost all experts displayed positive attitudes to exercise therapy and TC, concerning the potential for positive social, psychological, and physiological impact. However, many experts were less familiar with TC and 28/30 experts mentioned potential adverse effects, including injury and overtaxing patients [23]. This demonstrates that research on TC is likely not widespread among therapists since, contrary to these opinions, research from Luttenberger et al. (2021) demonstrated low injury rates and positive associations with participation. 

Conclusion

TC should be considered a valuable tool, as it combines the benefits of exercise and psychotherapy in a unique way to improve symptoms of depression and increase program adherence, without high costs or risk of injury. It is unclear what direction research on TC is headed. However, before TC becomes widespread, further research needs to be done with differing populations. TC is not a miracle solution for depression; it is key for research to develop guidelines on when and how TC should be implemented. Future studies could also investigate why climbing is more effective than other forms of exercise therapy, so TC frameworks and methods for implementation can be further refined.

Author's Note

I wrote this review for my UWP102B class with instructor Amy Goodman-Bide. I originally wanted to write about climbing because it is a sport that I have done for a long time and find uniquely interesting! I initially discovered that there are many areas of research within climbing but therapeutic climbing stood out to me for its novelty and the amount of current research. From a review perspective, readers should gain knowledge of current research within the therapeutic climbing space. Additionally, I hope that readers can appreciate the uniqueness of climbing and the potential benefits of expanding how we think about therapy.

References

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