The effectiveness of outdoor behavioral healthcare with struggling adolescents: A comparison group study a contribution for the special issue: Social innovation in child and youth services
Introduction
Adolescent mental health has become a significant societal concern, with 10–20% of adolescents meeting criteria for a diagnosable mental disorder (Kessler, Berglund, Demler, Jin, & Walters, 2005; Kieling et al., 2011; Merikangas et al., 2010). These disorders are especially disconcerting as they interfere with the accomplishment of normal development tasks (O'Connell, Boat, & Warner, 2009) and can lead to poor school performance, dropout, strained family and social relationships, involvement with the child welfare system, and other disruptive behaviors (Kapphahn, Morreale, Rickert, & Walker, 2006). In the juvenile justice system in the United States (US), it is estimated that 67% to 70% of youth have mental health disorders (Suowyra & Cocozza, 2006). Furthermore, with suicide being the third leading cause of death among adolescents in the US with between 500,000 and one million adolescents attempting suicide each year, 90% of these adolescents possess an underlying mental health disorder (National Center for Injury Prevention and Control, 2016; US Public Health Service, 1999). When left untreated or undertreated, adolescent mental health disorders often lead to adult mental health and chronic health concerns later in life (Belfer, 2008), including premature mortality (Brown et al., 2009). In fact, the US Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) estimates that 2.9 million youth receive professional services for emotional and behavioral problems per year.
Outdoor Behavioral Healthcare (OBH), sometimes referred to as wilderness therapy, is growing as an innovative and growing therapeutic intervention for adolescents struggling with emotional, behavioral, relational, and substance use disorders (Norton et al., 2014). Although various definitions of OBH and wilderness therapy have been proposed, the Manual of Accreditation Standards for Outdoor Behavioral Healthcare Programs describes OBH as the “the prescriptive use of wilderness experiences by licensed mental health professionals to meet the therapeutic needs of clients” (Gass et al., 2014, p. 1). Furthermore, key components of the OBH approach include:
(a) Extended backcountry travel and wilderness living experiences long enough to allow for clinical assessment, establishment of treatment goals, and a reasonable course of treatment not to exceed the productive impact of the experience.
(b) Active and direct use of clients' participation and responsibility in their therapeutic process.
(c) Continuous group living and regular formal group therapy sessions to foster teamwork and social interactions (excluding solo experiences).
(d) Individual therapy sessions, which may be supported by the inclusion of family therapy.
(e) Adventure experiences utilized to appropriately enhance treatment by fostering the development of eustress (i.e., the positive use of stress) as a beneficial element in the therapeutic experience.
(f) The use of nature in reality as well as a metaphor within the therapeutic process.
(g) A strong ethic of care and support throughout the therapeutic experience (Gass et al., 2014, p. 1).
OBH participants live in the wilderness in group settings, often learning primitive skills such as building fires without matches, backcountry navigation, and engaging in adventure experiences such as rock climbing, rappelling, backpacking, and mountain biking (Magle-Haberek, Tucker, & Gass, 2012).
OBH integrates psychological assessment and traditional psychotherapy models such as Adlerian theory (DeMille & Burdick, 2015), cognitive and behavioral therapies (Berman & Davis-Berman, 2008), psychodynamic therapy (Norton, 2010b), and Narrative Family Therapy (DeMille & Montgomery, 2016) in an outdoor treatment environment. Walsh and Golins (1976) were some of the first to describe the role of the outdoor environment in fostering change, asserting that the outdoors provides individuals with a contrasting environment to observe aspects of themselves often overlooked in a familiar environment. In other words, the outdoors provides a contrast for an individual to gain a new perspective on old patterns that occurred in their familiar environment.
Over the last 15 years OBH has received greater scholarly attention, especially in North America. General effectiveness studies have reported on youth who participate in treatment in an OBH program improve in overall mental health functioning from admission to discharge (Clark, Marmol, Cooley, & Gathercoal, 2004; DeMille, 2015; Magle-Haberek et al., 2012; Norton, 2008; Tucker, Norton, DeMille, & Hobson, 2016), with treatment gains maintained at six-months post-treatment (Bettmann, Russell, & Parry, 2012; Tucker, Norton, et al., 2016; Zelov, Tucker, & Javorksi, 2013), one-year (Behrens, Santa, & Gass, 2010; Combs, Hoag, Roberts, & Javorski, 2016; Lewis, 2012), and 18-months post treatment (Combs et al., 2016). In addition, participants in OBH programs have reported positive physiological outcomes (DeMille, Comart, & Tucker, 2014; Tucker, Norton, et al., 2016), decreased substance use (Lewis, 2012), decreased depressive symptoms (Norton, 2010a), improvements in mood (Russell, 2005), and decreased conduct disorder behaviors (Lewis, 2012). Studies have also been conducted on OBH in the juvenile justice system (Walsh & Russell, 2010), and adolescent offenders (Gillis & Gass, 2010; Gillis, Gass, & Russell, 2008).
Despite the depth of this research, only a few studies have managed to include comparisons groups, such as comparing matched experimental adventure groups and treatment-as-usual groups (TAU) (Gillis & Gass, 2010) as well as outdoor adventure groups to traditional psychosocial recovery groups (Schell, Cotton, & Luxmoore, 2012); however there is no such research on wilderness therapy (Becker, 2010; Bettmann et al., 2012; Clark et al., 2004; Combs et al., 2016; Norton et al., 2014). With the lack of comparison groups, the generalization of results and ability to establish efficacy is inhibited (Reamer & Siegel, 2008) which has fed criticism of OBH from different fields of mental health (Becker, 2010).
In addition, it is still unclear how gender, race, and age play a role in the impact of OBH on clients. Past research has shown that female participants typically enter OBH programs with higher levels of reported dysfunction than their male counterparts (Combs et al., 2016; Russell, 2003; Tucker, Norton, et al., 2016; Tucker, Paul, Hobson, Karoff, & Gass, 2016; Tucker, Smith, & Gass, 2014). However, at discharge some research has reported significantly lower levels of dysfunction for females than males (Russell, 2003; Tucker et al., 2014; Tucker, Paul, et al., 2016); as well as no differences at discharge or six months post discharge across gender (Combs et al., 2016). Similarly, research has not taken a specific look at race and ethnicity beyond reporting out the percent of Non-Caucasian participants (Lewis, 2012; Tucker, Paul, et al., 2016) and some research does not include this information at all due to a small percent of Non-Caucasian clients (Combs et al., 2016). In terms of age, since most clients who attend OBH are adolescents, little research has considered that there may be differences across younger and older adolescents. Combs et al. (2016) did explore if age was predictive of changes at discharge and at six months post discharge for OBH participants and found no impact in terms of age on outcomes. Tucker, Paul, et al. (2016) found that age was negatively correlated with length of OBH treatment; however, age was not significantly related to outcomes. Similarly, Combs et al. (2016) reported no difference in age between youth who were transported to OBH versus those who were not; however, they did not include age as a predictor of change over time but found no effect. Considering the developmental differences of youth who are 12 compared to those who are 17, research is needed to see if youth may show different changes based on their age at intake.
This study was designed to fill these research gaps as well as address the criticisms of a lack of comparison groups by comparing treatment in an OBH program to a treatment as usual (TAU) group. We sought to answer the following specific research questions:
- 1.
What were the pre-and post-differences reported by parents in youth functioning over time for youth involved in wilderness therapy treatment versus youth who received mental health care in their community (TAU)?
- 2.
Were there differences by gender, race, and age across time?
- 3.
What factors predicted youth functioning one year after an intake or parent's original inquiry about wilderness treatment?
Section snippets
Participants
The original sample included 147 participants in the treatment group and 60 participants in the comparison (TAU) group; however, for better validity, the treatment group was matched to the TAU group for analysis (i.e., 60 subjects placed in each group). To achieve the most appropriate matched design, the age of participants in the treatment sample was truncated to the nearest year to match the truncated format of the control group. Participants that did not fall between 12 and 17 years of age
Intake/inquiry to one-year post
Table 2 shows the means for participants in the study at Time 1 and Time 2. The ANOVA revealed significant main effects for Time [F(1) = 114.67, p < 0.001, partial eta2 = 0.493] and Group [F(1) = 10.22, p = 0.002, partial eta2 = 0.080] as well as a significant interaction between Time x Group [F(1, 118) = 25.61, p < 0.001, partial eta2 = 0.178]. It is important to note that youth in the OBH group had mean improvements on the Y-OQ 2.01 as reported by parents that were 2.75 times larger than
Intake/inquiry to one-year post
The current study found that treatment in an OBH program decreased symptomology for adolescents at one-year post treatment as reported by their parents. Clinically and statistically significant improvements were reported by parents of youth in both the OBH group and the TAU group. However, the gains in the OBH treatment group were significantly greater than the TAU comparison group, almost three times larger in fact. These results support the idea that this OBH interventions served the
Limitations
Despite the promise of our findings, there are several limitations important to recognize. A common limitation of research in OBH is the lack of a comparison group in treatment studies as well as a lack of follow up data on participants after they leave treatment. This study aimed to address both gaps; yet randomization of treatment conditions was not possible for this study due to ethical and logistic constraints (Gabrielsen, Fernee, Aasen, & Eskedal, 2016). Despite the OBH and TAU groups
Conclusion
As mental health and substance abuse problems in adolescence are increasing and behavioral health treatments are becoming more complex, it is important that research be invested in exploring alternatives to clinical treatment interventions. The current results strengthen an area of OBH research that has been long called for by including a comparison group (Becker, 2010; Clark et al., 2004, Gass et al., 2012; Norton et al., 2014). Randomized control trials (RCTs) have traditionally been
Funding
This work was supported in part by the Associated Charities of Baltimore and the Outdoor Behavioral Healthcare Council; however these sources had no influence on the research design, data collection, data analysis or choice of where to publish these findings.
Declaration of interest
Brett Talbot is an employee of RedCliff Ascent. Brett Talbot was not a part of the data collection or data analysis. Brett only contributed to the writing of the introduction and discussion sections. Steven DeMille is an employee of RedCliff Ascent and is responsible for supervising program research. Steven was part of the data collection through sending email reminders to participants to complete online surveys and questionnaires. Steven was not involved in the data analysis or reporting.
There
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