Wilderness Therapy Or Outdoor Behavioral Healthcare

Objective

The objective of this paper is to provide a literature review of previous research studies conducted on the mental health outcomes of adolescents and young adults in wilderness therapy programs to increase knowledge on the subject.

Search Methods

The sources included in this literature review were collected using the online library databases PsycINFO and Academic Search Complete. Articles were located using the following search terms: “wilderness therapy,” or “outdoor behavioral healthcare” and, “adolescents, teenagers, or young adults,” and, “mental health.” The search was limited to articles that were peer-reviewed and published after 2008.

After duplicates were excluded, 52 articles remained. Articles that focused on adventure therapy were then excluded, as adventure therapy is typically a more short-term treatment than wilderness therapy. Article content was then reviewed to ensure that the articles addressed outcomes of wilderness therapy related to mental health. Articles that concentrated on family therapy or detailed studies outside of the U.S. were also excluded, resulting in the eight articles that will be discussed in this literature review.

Introduction

The emergence of wilderness therapy, which is sometimes referred to as outdoor behavioral healthcare stems from the need to address the high levels of mental health diagnoses in adolescents and young adults. In this literature review, adolescents will be defined as being between the ages of 13 and 18, and young adults will be defined as being between the ages of 18 and 25. In the U.S., 21% of adolescents are considered to be affected by some form of mental health disorder (Tucker, Smith, & Gass, 2014). Adolescents and young adults with mental health disorders may be at risk for long-term problems including increased risks of school drop-out, difficulty maintaining relationships with peers and family, increased chance of being involved in the juvenile justice system, substance abuse, and suicide (DeMille et al.

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, 2018).

Wilderness therapy programs were established to address the gap in traditional treatment for adolescents and young adults with mental health disorders. Wilderness therapy has been defined as “the prescriptive use of wilderness experiences by licensed mental health professionals to meet the therapeutic needs of clients” (DeMille et al., 2018 p. 241). Wilderness therapy is a residential treatment model often utilized when traditional forms of treatment such as outpatient therapy, or psychiatric hospitals are unsuccessful (Bettmann, Tucker, Behrens, & Vanderloo, 2017). Wilderness therapy programs are typically designed for adolescents and young adults and programs on average last seven to nine weeks (Bettmann et al., 2017). The most common diagnoses seen in wilderness therapy program clients are mood disorders, substance use, and anxiety (Roberts, Stroud, Hoag, & Massey, 2017). Wilderness therapy programs implement wilderness living and adventure experiences, group living, individual and group therapy, and the support of a licensed mental health professional (DeMille et al., 2018). The main difference between wilderness therapy programs and residential treatment centers is the setting of the wilderness, which has been described as serving an important part of the change process (Hoag, Massey, Roberts, & Logan, 2013). The wilderness is utilized based on the theory that a new environment allows for clients to separate themselves from distractions or self-destructive behaviors while promoting self-efficacy and self-responsibility through wilderness skills (Hoag et al., 2013). Intended outcomes for clients of wilderness therapy include: a decrease in symptoms, and an increase in healthy behaviors (Roberts et al., 2017).

Review

In all studies reviewed, results indicated that clients entered treatment with significant levels of emotional or behavioral dysfunction, and upon discharge were in normal functioning range (Combs, Hoag, Javorski, & Roberts, 2016). The studies analyzed for this review utilized quantitative data to determine outcomes of wilderness therapy on individuals. Though other forms of data collection were used, the majority of the studies used a Youth Outcome Questionnaire (Y-OQ) completed by parents of adolescents, a Youth Outcome Questionnaire Self-Report (Y-OQ SR) completed by adolescents or, Outcome Questionnaire 45 (OQ-45) completed by young adults. The Y-OQ and Y-OQ SR are widely used during psychological treatments to measure behavioral change and have high levels of validity, consistency, and reliability (Gillis et al., 2016). The Y-OQ and Y-OQ SR measure intrapersonal distress, somatic, interpersonal relations, social problems, behavioral dysfunction, and critical items (Gillis et al., 2016). OQ-45 is a self-report that tracks client progress during and after treatment and measures symptom distress, social role performance, and interpersonal relationships (Bettmann et al., 2017). OQ-45 has been shown to have high levels of consistency, validity, and reliability (Bettmann et al., 2017).

Comparison Group Findings

Gillis et al. (2016) conducted a meta-analysis of outcomes from 21 wilderness therapy programs and compared these results to outcomes from traditional residential treatment. This meta-analysis utilized data from Y-OQs and Y-OQ-SRs to measure behavioral change pre and post treatment (Gillis et al., 2016). Gillis et al. (2016) found that there are large treatment effects seen in clients of wilderness therapy, however, these treatment effects are also seen in clients in residential treatment. Gillis et al. (2016) discovered that parents reported higher effects in wilderness therapy programs, but youth self-reported higher effects in other settings. DeMille et al. (2018) discovered when comparing Y-OQs from clients of wilderness therapy to Y-OQs from clients who completed treatment as usual (TAU) through outpatient therapy or medication management, that clinically and statistically significant change was seen in both groups. However, gains in the clients of wilderness therapy were almost three times greater than those who participated in TAU (DeMille et al., 2018). These results indicate that wilderness therapy is an effective treatment, but other comparison studies should be conducted to determine if the setting of the wilderness produces unique outcomes in comparison to residential treatment.

Gender as an Independent Variable in Treatment Outcome

Another theme seen in research studies on wilderness therapy outcomes is the differences in individuals demographically and how this affects outcomes post-treatment. Overall, wilderness therapy programs tend to have an average of 70% male clients (Combs et al., 2016). Four studies chose to use gender as an independent variable to determine if outcomes of wilderness therapy differ based on the gender of clients. Three out of four studies found that female clients report more progress and improvement compared to male clients.

Combs et al. (2016) found that Y-OQ SRs completed by adolescent clients pre, during, and post treatment showed that female clients entered the program with higher levels of symptom severity compared to male clients, but female clients improved quicker than male clients and showed less symptom severity post-discharge. Findings by Tucker et al. (2014) also provide evidence that in Y-OQ reports of wilderness therapy clients, female adolescent clients have reported clinical change 3.5 times greater than male clients. This finding was similar to research conducted by Hoag et al. (2013) which utilized OQ-45, to determine that young adult female clients assessed their overall functioning as worse than male clients in pre-tests, but assessed their overall functioning as better than male clients in post tests.

However, when analyzing Y-OQ results, DeMille et al. (2018) found that gender was not a significant factor in clinical change and that male and female adolescent clients showed equal improvements at post-tests following wilderness therapy programs. When gender is used as an independent variable to determine wilderness therapy outcomes, it is clear based on Y-OQs, Y-OQ SRs, and OQ-45 results from these studies, that female clients, show improvement on an equal or greater level than male clients. Tucker et al. (2014) states that the reason for this is still unclear but could be a result of the group format of the program or the wilderness activities and experiences that promote empowerment. These findings should serve to help wilderness therapy programs overcome gender differences and increase female client numbers in a therapy setting that has traditionally served male clients (DeMille et al., 2018).

Mood Disorders and Wilderness Therapy Outcomes

An additional factor that plays a role in the outcomes of wilderness therapy is the diagnosis of the client. In a study conducted by Bettmann et al. (2017), clients who entered treatment diagnosed with depression, reported greater change on OQ-45 than clients who entered the program without a depression diagnosis. In the study by Combs et al. (2017), the majority of clients in the study entered treatment with a mood disorder diagnosis, and these clients assessed themselves with greater symptom severity, but showed a greater rate of change on Y-OQ SRs than clients without a mood disorder diagnosis.

Longitudinal Outcomes

Another theme seen throughout several of the articles reviewed is the longitudinal outcomes of wilderness therapy in adolescents and young adults. DeMille et al. (2018) and Combs et al. (2016) utilized Y-OQ SRs to assess change in clients pre, during, and post treatment. Both studies found that Y-OQ SRs indicated that clients significantly improved from intake through treatment and maintained steady levels of mental health functioning a year after discharge (DeMille et al., 2018; Combs et al., 2016). Roberts et al. (2016) noted similar clinical and statistical changes in the results of a Y-OQ completed a total of six times from intake to 18 months post-discharge. The changes seen in adolescents were also seen in young adults as Hoag et al. (2013) found through OQ-45 that clients gradually improve throughout treatment and show clinical and statistical change up to a year following discharge. Limitations of these longitudinal studies are that as the amount of time post-discharge increased, response rates from clients decreased and follow-up results may not be representative of the sample (Hoag et al., 2013).

Limitations

Authors noted similar limitations in their studies. Gillis et al. (2016) and Tucker et al. (2016) both indicated missing data as a limitation to generalizing the results of their studies. Several articles noted that a control group should be implemented in the future to improve validity (Bettmann, Gillis, Speelman, Parry, & Case, 2016; Bettmann et al., 2017; Combs et al., 2016; Roberts et al., 2016). DeMille et al. (2018) noted that although the study did have a comparison group, there could be significant differences between the TAU group and the wilderness therapy group and that this lack of randomization decreases the validity of results. Another limitation seen is the homogenous population of mostly White clients. Due to this, results cannot be generalized to other racial groups (Bettmann et al., 2017). Lastly, an important consideration in regard to the results of the studies is the funding and author’s connection to wilderness therapy programs. Research by Combs et al. (2016) and Hoag et al. (2013) was funded by Second Nature Wilderness programs. Joanna Bettmann, who co-authored two of the studies reviewed is the co-owner of one of the programs where the study was conducted (Bettmann et al., 2017). Understanding these conflicts of interest is important to consider when reviewing results.

Implications for Social Work

The results from all research studies analyzed indicate that wilderness therapy programs produce improvements in the overall mental health functioning of both male and female adolescent and young adult clients. This finding indicates that wilderness therapy programs may be an effective treatment for adolescents or young adults in need of therapeutic interventions due to mental health disorders. Adolescents with mood disorders who have not had success in traditional therapeutic treatments may especially benefit from wilderness therapy.

Conclusions

Though findings from the studies reviewed indicated that wilderness therapy is an effective therapeutic treatment for adolescents and young adults, there are some questions regarding the strength of the evidence resulting from the studies. Studies that completed a meta-analysis lack the ability to generalize their results as many different wilderness programs with different components, length of stay requirements, and therapeutic treatments were lumped together in one analysis (Bettmann et al.,2016). This means that outcomes from very different programs could be analyzed together, so there is no means to determine which types of wilderness therapy programs produce effective change. Additionally, lack of a true control group and randomization in all studies affects the validity of the results and data. Data from most studies reviewed came from quantitative forms of questionnaires. Data from questionnaires came from self-reports or reports from parents, however, using multiple informants to better analyze outcomes should be implemented in the future for all studies (DeMille, et al. 2018). Utilizing additional qualitative data in the future may be beneficial to a greater understanding of wilderness therapy program outcomes. Data in this review was also limited to participants that completed the program, but obtaining data from individuals who did not complete the program may provide a more complete picture of what population best benefits from wilderness therapy.

Next Steps

Additional comparison studies should be conducted to determine if wilderness therapy does produce better results that residential treatment centers. This research could help to indicate the specific aspects of wilderness therapy programs that promote improvement in clients. The response rate from longitudinal studies was low following discharge from programs, so additional studies should be conducted in order to obtain a more representative sample. Another step that should be considered in the future is the diversity of the clients studied. Wilderness therapy should strive to better meet the needs of a diverse group of clients and additional research should be conducted to determine outcomes when a more diverse population is studied. Lastly, studies should be conducted that are not funded by wilderness therapy programs or authored by individuals with ties to these programs. This step could ensure that results from studies are not biased.