enlightened my understanding of the field and illuminated the greater importance of ...... The final section of this review explores family involvement in adolescent ..... alliance formed between therapist and client (Barber, Connolly, Crits-Christoph, ..... For any research to be deemed valuable it needs to provide the reader with.
A Mixed Methods Examination of Family Involvement in Adolescent Wilderness Therapy
A DISSERTATION SUBMITTED TO THE FACULTY OF THE GRADUATE SCHOOL OF THE UNIVERSITY OF MINNESOTA BY
Nevin J. Harper
IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY
November 2007
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Acknowledgements With the closure of this three-year academic adventure, and specifically bringing closure to a study such as this, it is necessary to acknowledge those who truly made it possible for me. First and foremost, I express my deepest gratitude for my beautiful wife Jocelyne. Her continued love and support has provided me with stability and focus through numerous challenging times. To my insightful and fun-loving son Isaac, who kept me sane with regular Lego sessions and toddler advice, I am indebted. To my daughter who shall join us at the time this thesis goes to print, thank you for the motivation to finish in a timely manner and get the family settled in back home. The most sincere appreciation to my parents for providing me with opportunities to choose my own path, for instilling in me a sense of loyalty to family and friends, and arming me with a streak of stubborn determination. Special thanks to my adviser, mentor and colleague, Dr. Keith Russell, for your unwavering support and encouragement. Thank you for bringing me along, to join you in asking some critical questions about the work that we know, and care about deeply. Further, thanks are due to my committee, Keith for your detailed reviews and pointy questions, Dr. Leo McAvoy for your theoretical challenges, feedback and academic career advice, and Dr. Stephen Ross and Dr. Diane Weis-Bjornstal for your thoughtful suggestions, diverse perspectives and insight. Your collective guidance and input will serve me well. Sincere gratitude is due to the families participating in this study that have enlightened my understanding of the field and illuminated the greater importance of family in general. Your openness and willingness to inform this study is of significant value to others who will benefit from your contributions, my heartfelt thanks. Without the support of Catherine Freer Wilderness Therapy Expeditions and Aspen Achievement Academy, their field staff and therapists, clinical and administrative staff, and the initial sponsorship of the outdoor behavioral healthcare research cooperative, none of this would have been possible. Thank you for trusting me in working so closely with your staff and clients. Last, I need to acknowledge my colleagues in the field, past and present, paddling the coastlines, post-holing to summits in wet snow, sleeping on the ground and picking pine needles and dirt from their food day in and out; you are the heart and soul of the work, gracias. And last, I am grateful to all those children and youth I have been privileged to travel in the wilderness with. Those journeys are forever etched in my memory and fuel my passion to continue learning about the role of nature in our lives. The reality of your experiences keep me grounded; for that, a heartfelt thanks.
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Abstract Adolescent wilderness therapy (WT) programs profess to operate from a family systems perspective. However, few studies have empirically examined the nature and extent of family involvement and the role it plays in facilitating treatment outcome. To address this research need, this study sought to illuminate the theoretical basis, processes and outcomes of family involvement in WT. A mixed-methods research approach was utilized to capture the lived experiences of families in WT as well as measure outcome through assessment of family function, adolescent social and psychological well-being and child-therapist/leader and parent-therapist therapeutic alliances. A case-study of two WT programs included fourteen families in the qualitative phase which included interviews, observation and review of archival materials. WT program filed staff, therapists and administrators were also interviewed and observed to further explore family involvement. Qualitative findings revealed significant family crisis being stabilized by the WT intervention, the majority of families participating actively in mandatory educational treatment processes and an increasing awareness of family system dynamics. A longitudinal repeated-measures design was utilized with one hundred and fifteen adolescents and eighty-five parents in the quantitative phase. Measures were administered to assess change in adolescent outcomes, family functioning, and working alliances. Results of quantitative analysis showed significant improvements in a number of adolescent and family function indices. Further analysis demonstrated change occurring inconsistently across several client and program-level variables. Measures were not correlated on outcomes and age and gender combined as pre-treatment demographics, provided a six percent explanation of outcome. Adolescents reported perceiving significant improvements in general family functioning. Triangulation of qualitative and quantitative findings provided both complimentary and contradictory understandings of family involvement. Measures of family functioning and adolescent outcomes provided a picture of a general improving trend, as did qualitative findings of stabilized family crisis and the recognition that further treatment and support was needed. Measures of family function did not demonstrate significant change within the family system, qualitatively however, families expressed a strong positive impact from their involvement in WT.
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TABLE OF CONTENTS ACKNOWLEDGMENTS....................................................................................................i ABSTRACT.……………….………………………………..………………….………...ii TABLE OF CONTENTS ...…………………………………………….…………….….iii LIST OF TABLES ...……………………………………………………….……..……viii LIST OF FIGURES…………………………………………………………………….…x CHAPTER ONE: INTRODUCTION……………………………………………………..1 Wilderness Therapy ............................................................................................................ 2 Wilderness Therapy and the Family ................................................................................... 3 Family Involvement in Adolescent Treatment ................................................................... 4 Outdoor Behavioral Healthcare .......................................................................................... 5 Purpose of Study ................................................................................................................. 6 Research Objectives .................................................................................................... 6 Theoretical and Model Foundations ........................................................................... 7 Definitions ................................................................................................................... 7 CHAPTER TWO: REVIEW OF RELATED LITERATURE.......................................... 10 Exploring Family Involvement in Adolescent Wilderness Therapy................................. 10 Locating Wilderness Therapy within Adventure Therapy................................................ 11 Wilderness Therapy Theory and Definitions .................................................................... 12 Wilderness Therapy Process ..................................................................................... 13 Research in Adventure and Wilderness Therapy .............................................................. 14 Meta-Analyses on the Effects of Adventure-based Programs ................................... 14 Limitations of Current Knowledge............................................................................ 16 Empirical Support from Other Fields ....................................................................... 18 Wilderness Adventure Therapy ................................................................................. 19 Research in Outdoor Behavioral Healthcare..................................................................... 20 Systematic OBH Research to Date............................................................................ 21 Descriptive Analysis of Family Involvement in OBHRC Member Programs ........... 24 iii
Families and Therapeutic Wilderness Programs............................................................... 25 Family Involvement in Adventure Therapy...................................................................... 28 Family Involvement in Adolescent Treatment: Theoretical Framework, Process, and Outcomes .......................................................................................................................... 32 Family Systems Theory ............................................................................................. 32 Systems and the Change Process .......................................................................... 32 Healthy Family Functioning ................................................................................. 33 The Family Defined ................................................................................................... 35 Empirical Support for Family Involvement in Adolescent Treatment ...................... 36 Types of Family Involvement ............................................................................... 37 Levels of Therapeutic Engagement ........................................................................... 39 Psycho-educational ............................................................................................... 39 Counseling ............................................................................................................ 40 Psychotherapy ....................................................................................................... 41 Family Involvement Types ........................................................................................ 41 The Working Alliance ............................................................................................... 42 Predictor of Outcomes .......................................................................................... 42 Alliance and the Family ........................................................................................ 43 Summary of Literature Reviewed ..................................................................................... 44 CHAPTER THREE: METHODOLOGY ......................................................................... 47 Introduction ....................................................................................................................... 47 Mixed-Methods as a Research Approach ................................................................. 47 Qualitative: Phase I ........................................................................................................... 50 Participants ............................................................................................................... 51 Program Selection ................................................................................................. 51 Participant Selection ............................................................................................. 51 Population Description.......................................................................................... 53 Treatment Protocol................................................................................................ 53 Data Collection Methods .......................................................................................... 54 Researcher and Participant Observation ............................................................... 54 Participant Interviews ........................................................................................... 57 Data Management and Analysis ............................................................................... 58 Trustworthiness ......................................................................................................... 59 Quantitative: Phase II........................................................................................................ 61 Research Aims and Hypotheses: Phase II ................................................................ 61 Constructs and Instrumentation ................................................................................ 62 iv
Brief Family Assessment Measure ....................................................................... 62 Youth Outcome Questionnaire ............................................................................. 64 Working Alliance Inventory ................................................................................. 65 Variables ................................................................................................................... 67 Independent Variables .......................................................................................... 67 Dependent Variables ............................................................................................. 67 Participants ............................................................................................................... 67 Program and Participant Selection ........................................................................ 67 Sample Size and Attrition ..................................................................................... 67 Procedures ................................................................................................................ 68 Time-Series Repeated-Measure Design ................................................................ 68 Data Collection ..................................................................................................... 70 Data Analysis ........................................................................................................ 70 Mixed-Methods Triangulation .......................................................................................... 72 Converging Inquiries ................................................................................................ 72 Procedures ............................................................................................................. 72 Limitations ............................................................................................................ 73 Ethical Considerations ...................................................................................................... 73 Risks .......................................................................................................................... 73 Benefits ...................................................................................................................... 74 Ethical Procedures .................................................................................................... 74 Internal Review Board ...................................................................................................... 76 CHAPTER FOUR: FINDINGS ........................................................................................ 77 Qualitative phase ............................................................................................................... 77 Family involvement: Programmatic differences ....................................................... 77 Catherine Freer Wilderness Therapy Expeditions ................................................ 77 Aspen Achievement Academy.............................................................................. 80 Qualitative Results .................................................................................................... 82 Theory ....................................................................................................................... 84 Integrated Treatment Model ..................................................................................... 85 Wilderness Setting ................................................................................................ 89 Safe Place .............................................................................................................. 93 Process ...................................................................................................................... 96 Family Crisis ......................................................................................................... 96 Meaningful Separation .......................................................................................... 98 Family Issue ........................................................................................................ 102 Meaning .................................................................................................................. 105 Mixed Emotions .................................................................................................. 106 Touchstone Experience ....................................................................................... 108 v
Abrupt Transitions .............................................................................................. 111 Outcome .................................................................................................................. 114 Sense of Self ....................................................................................................... 115 New Beginnings .................................................................................................. 117 Not Fixed ............................................................................................................ 120 Two Illustrative Case Studies ......................................................................................... 123 The Jackson Family: Aspen Achievement Academy ............................................... 125 The Walker Family: Catherine Freer Wilderness Therapy Expeditions ................ 128 Summary of Qualitative Results ..................................................................................... 131 Quantitative Results ........................................................................................................ 133 Participant demographics ....................................................................................... 133 Response Biases ...................................................................................................... 137 Family Function .............................................................................................................. 138 Adolescent Outcomes ..................................................................................................... 144 Working Alliance ............................................................................................................ 147 Correlations ..................................................................................................................... 150 Multiple Regressions: Variables Predicting Outcome .................................................... 151 Summary of Quantitative Results ................................................................................... 153 CHAPTER FIVE: DISCUSSIONS, CONCLUSIONS AND RECCOMENDATIONS.161 Discussion ....................................................................................................................... 156 Family involvement intensity and the lived experience .......................................... 156 Systemic Change and Systems of Support ............................................................... 162 Client and program variables related to outcome .................................................. 171 Family Functioning (BFAM) .............................................................................. 172 Adolescent Social and Psychological Wellbeing (YOQ) ................................... 176 Age and gender ................................................................................................... 179 Diagnoses ............................................................................................................ 183 Treatment length and working alliance............................................................... 185 WT as stabilizing intervention ................................................................................ 189 Conclusions ..................................................................................................................... 195 Research Questions ................................................................................................. 195 1: What theory guides family involvement in WT?............................................ 195 vi
2: What processes are utilized in working with families in WT? ....................... 197 3: What meaning does the WT experience hold for families? ............................ 199 4: What outcomes were experienced by families in WT? .................................. 200 Recommendations for wilderness therapy programs .............................................. 201 1: Programming family involvement .................................................................. 201 2. Impact on larger systems of support ............................................................... 202 3. Increase family motivation and participation in change process .................... 202 4. Communication systems ................................................................................. 203 Recommendations for future WT research.............................................................. 203 5. Healthy family function revisited ................................................................... 203 6. Perceptions of therapy..................................................................................... 204 7. Client appropriateness ..................................................................................... 204 8. Long-term family follow-up ........................................................................... 205 Final comments ....................................................................................................... 205 REFERENCES ............................................................................................................... 209 APPENDICES ................................................................................................................ 229 A. Participating Wilderness Therapy Programs of OBH ................................................ 229 B. Internal Review Board Ethics Approval .................................................................... 230 C. Collaboration Letter: CFWT ...................................................................................... 232 D. Collaboration Letter: AAA ........................................................................................ 233 E. Client Consent Form................................................................................................... 234 F. Parent Consent Form .................................................................................................. 235 G. Research Cover Letter for Participants ...................................................................... 236 H. Brief Family Assessment Measure ............................................................................ 237 I. Youth Outcome Questionnaire .................................................................................... 240 J. Working Alliance Inventory........................................................................................ 244 K. Qualitative Interview Questions................................................................................. 245
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LIST OF TABLES
Table 1. Table 2. Table 3. Table 4. Table 5. Table 6. Table 7: Table 8. Table 9. Table 10 Table 11 Table 12 Table 13 Table 14. Table 15. Table 16: Table 17: Table 19: Table 19. Table 20. Table 21. Table 22.
Depth of intervention in adventure therapy: Relationship to treatment, duration and examples .................................................................................... 29 Examples of family involvement in adventure therapy literature: Definitions, modality, depth and duration of intervention .................................................. 30 Constructs and measures for quantitative analysis: Phase II .......................... 62 Repeated measures timeline of Phase II quantitative study ............................ 69 Characteristics of family involvement at participating wilderness therapy programs ......................................................................................................... 80 Research aims, pattern codes and descriptive codes of family involvement in wilderness therapy .......................................................................................... 83 Pattern code Theory: Integrated Approach with descriptive codes, definitions and examples of coded responses ................................................................... 86 Pattern code Theory: Wilderness Setting with descriptive codes, definitions and examples of coded responses ................................................................... 90 Pattern code Theory: Safe Place with descriptive codes, definitions and examples of coded responses .......................................................................... 94 Pattern code Process: Family Crisis with descriptive codes, definitions and examples of coded responses .......................................................................... 97 Pattern code Process: Meaningful Separation with descriptive codes, definitions and examples of coded responses ................................................. 99 Pattern code Process: Family Issue with descriptive codes, definitions and examples of coded responses ........................................................................ 103 Pattern code Meaning: Mixed Emotions with descriptive codes, definitions and examples of coded responses ................................................................. 106 Pattern code Meaning: Touchstone Experience with descriptive codes, definitions and examples of coded responses ............................................... 109 Pattern code Meaning: Abrupt Transitions with descriptive codes, definitions and examples of coded responses ................................................................. 112 Pattern code Outcome: Sense of Self with descriptive codes, definitions and examples of coded responses ........................................................................ 115 Pattern code Outcome: New Beginnings with descriptive codes, definitions and examples of coded responses ................................................................. 118 Pattern code Outcome: Not Fixed with descriptive codes, definitions and examples of coded responses ........................................................................ 121 Vignette family’s composition, program attendance, presenting issues, adolescent and family outcomes and two-month post-program status ......... 124 Frequency and relative percentage of participants by program, gender and age ....................................................................................................................... 135 Substance use, mental health, and dual-diagnoses of clients entering wilderness therapy programs ........................................................................ 136 Scores from parent BFAM self-rating and general scales including pretreatment and post-treatment totals and results by program ......................... 139 viii
Table 23. Scores from adolescent BFAM self and general measures including pretreatment and post-treatment comparisons by participant and program variables ........................................................................................................ 140 Table 24. Scores on adolescent YOQ including pre-treatment and post-treatment comparisons by program, gender, age, treatment length group and diagnosis group variables .............................................................................................. 145 Table 25. Scores on adolescent and parent WAI including pre-treatment and posttreatment by program, gender, age group, treatment length group and diagnosis group variables .............................................................................. 148 Table 26. Correlations of pre-treatment to post-treatment score differences on adolescent YOQ, self and general scales of BFAM and WAI ...................... 150 Table 27. Bivariate and partial correlations of predictor variables for YOQ outcomes and percentage of variance explained ........................................................... 153
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LIST OF FIGURES Figure 1.
Mixed-methods model with concurrent triangulation strategy and adolescent, parent and staff as unit of analysis…………………….……………...……..59
Figure 2.
Intensity of experience for parental involvement in adolescent wilderness therapy programming ……………………………………………………...159
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CHAPTER ONE: INTRODUCTION AND OVERVIEW The United States is encountering a significant adolescent mental health crisis. An estimated 2.7 million children who experience severe emotional or behavioral problems are not yet receiving appropriate treatment (National Institute of Mental Health, 2005). These treatment shortages have existed for more than a decade (American Psychological Association, 1989; Surgeon General, 2001) and are being responded to by a shift from institutionalized to community-based treatment of mental health and substance abuse disorders to better meet the needs of consumers (Lyons, 1997). Alternative methods such as residential and intensive outpatient services are more commonly utilized (Sack, 1999) and both internal and external assessments of outcomes are assisting service providers in demonstrating efficiencies, success, and guiding practices (Lyons, 1997; Newes, 2001). Parents will seek alternative treatment modalities for their children when conventional practices are not available or appropriate in meeting the child or parents need (e.g., services which adolescents are unlikely to continue until desired treatment has been achieved). One treatment modality receiving growing attention for promising outcomes with high-risk / high-needs adolescents is wilderness therapy (WT). There are now more than 100 programs operating in the United States, providing mental health treatment to over 10,000 adolescents annually (Russell, 2003a). However, a clear understanding of the WT process and its role as an effective adolescent mental health treatment has yet to be articulated (Russell, 2001). 1
Wilderness Therapy WT integrates conventional therapeutic interventions with challenge-based activities conducted in wilderness environments and has only recently begun to demonstrate promising outcomes for adolescents with emotional and behavioral disorders (see Clark, Marmol, Cooley, & Gathercoal, 2004; Crisp & Hinch, 2004; Russell & Phillips-Miller, 2002). While these research efforts are providing necessary understanding and legitimacy for insurance, licensure, and third-party funding (Newes, 2001; Russell, 2001), related literature and empirical support of treatment efficacy is limited. WT is located in a larger collective of therapeutic modalities referred to as adventure therapy (Gass, 1993; Gillen, 2003) and characterized by the use of wilderness or similar natural environments, experiential teaching and learning methodology, and risk-related adventure activities combined with individual and group therapy. An array of wilderness and adventure-based programs has been reviewed for effectively initiating participant change and generally demonstrated positive impacts on interpersonal and intrapersonal outcomes (Hattie, Marsh, Neill, & Richards, 1997) although most studies have not demonstrated effect sizes reported in reviews of adolescent treatment outcomes (Neill, 2003). The majority of WT studies have focused primarily on adolescent client outcomes. Long-term effectiveness of adolescent WT interventions, process variables related to treatment outcomes and the impact WT may have on the family system have received limited attention, suggesting the need for further investigation (Bandoroff & Scherer, 1994; Russell, 1999; Wells, Widmer, & McCoy, 2004).
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Wilderness Therapy and the Family WT programs primarily serve adolescent clients and do not often work directly with families (Wells et al., 2004) due to fiscal and logistical constraints. Isolated program locations, physical distance between home and programs, and the length of adolescent treatment are a few contributing factors limiting family involvement. Wells et al. (2004) described the costs and logistical limitations associated with delivering programs and conducting research on wilderness programs involving families. While not specifically using wilderness environments, 85% of adventure-based therapeutic programs surveyed reported providing as little as one hour to one full day of inclusive family treatment, with only a few programs offering multi-day family interventions (Gillis et al., 1992). Family involvement research in WT and closely related programs is limited to a handful of publications from dissertation studies (e.g., Bandoroff & Scherer, 1994; Pommier & Witt, 1995) in addition to more recent investigations (e.g., Harper, Russell, Cooley, & Cupples, 2007). While these studies suggest potential benefits of family involvement in the WT process, limitations in methodology and the need for further research to understand the phenomena has been expressed. Current literature describes the need for further investigation of WT theory and process to inform effective family involvement (see Burg, 2001; Russell, 2005; Russell & Phillips-Miller, 2002). Recognizing the potential positive impact that family involvement in adolescent treatment brings, there is a demonstrated need to understand the type and depth of family involvement in the treatment process, and subsequently, how this involvement relates to outcomes for adolescents and the family. 3
Family Involvement in Adolescent Treatment Family therapy and family involvement in adolescent therapy has demonstrated increased positive benefits relative to treatment of the adolescent alone (see Cottrell & Boston, 2002; Diamond, Serrano, Dickey & Sonis, 1996; Fauber & Long, 1991; Liddle et al., 2000). This shift from individual therapy to family-based interventions has been strongly influenced by family systems theory (Becvar & Becvar, 1999) which is manifest in the integration of systems theory with psychotherapy (Beels, 2002). The belief that the family contributes to child and adolescent emotional and behavioral well-being, and dysfunction, is shared among mental health service providers in behavioral, psychoeducational, and systems models (Diamond et al., 1996). Family involvement has been demonstrated to be a major predictor of outcomes in preventative work with delinquent adolescents (Kumpfer, 1999), adolescent substance abuse (Kumpfer, Alvarado, & Whiteside, 2003), education-related problems, and as a mediator of negative peer influence (Kerr, Beck, Shattuck, Kattar, & Uriburu, 2003). Child or adolescent-only interventions have shown to be less effective than family-based interventions (Kumpfer, 1999) and may even produce deteriorated negative behaviors in the case of high-risk population groups (Dishion & Andrews, 1995). Beyond preventative work, the benefit of family involvement in psychological therapy for a wide range of child and adolescent pathology has been reviewed and supported in current family-therapy literature (Diamond, Siqueland, & Diamond, 2003; Kazdin & Whitley, 2003; Liddle, 1996) although only a few controlled studies have begun to shed light on how and when to most effectively involve families (e.g., Eisler et al., 2000; Robin, Siegal, & Moye, 1995). 4
The strength of a therapeutic or working alliance between client and therapist has related to improved outcomes in adolescent treatment (Diamond, Diamond, & Liddle, 2000; Horvath & Symonds, 1991; Klein et al., 2003). A strong alliance developed earlier in the therapeutic relationship may be more predictive of outcomes (Hogue, Dauber, Stambaugh, Cecero, & Liddle (2006) and a similar alliance between parents and therapists supports treatment completion and adolescent outcomes suggesting mental health service providers need to encourage family involvement to optimize potential outcomes for adolescents in treatment. Outdoor Behavioral Healthcare Outdoor Behavioral Healthcare (OBH) is a term used to describe programs utilizing WT in the treatment of children and adolescents with emotional and behavioral difficulties (Russell, 2001). WT in OBH programs has developed over the last two decades integrating principles and practices of education, sociology, psychology, communication, and outdoor recreation (Bandoroff & Scherer, 1994; Burg, 2001; Russell, 1999, 2001; Wells et al., 2004). The research and publications of OBH have provided a foundation for numerous WT programs to start addressing their theoretical and clinical understanding of practice (Russell, 2000, 2001, 2006a; Russell & Hendee, 2000; Russell & Phillips-Miller, 2002). In addition to family involvement, the therapeutic alliance has been shown across models of treatment to be critical in effective outcomes. Further, a parent-therapist alliance has also been demonstrated to contribute to adolescent outcomes (Diamond, Diamond, & Liddle, 2000). To the degree OBH programs emulate these factors is critical and worth empirical examination. 5
Purpose of Study Research on family involvement in adolescent treatment has empirically demonstrated that it is superior to adolescent treatment alone (Liddle et al., 2000). This notion supports the foundation of this study which sought to examine family involvement in the WT treatment process which has traditionally focused research on adolescent outcomes (Burg, 2001; Wells et al., 2004). The family is an under-examined unit of measure in adolescent WT and while family literature in WT started to indicate support for family involvement, it remains inconclusive on the role or ideal level of family involvement. Questions raised from previous family WT research (e.g., Bandoroff & Scherer, 1994) include: How and when should WT programs involve families in the treatment process? What format or depth of involvement will increase positive outcomes for adolescent clients and their families? And finally, what outcomes can families expect from WT treatment in terms of improved family functioning? To address these questions, this study aimed to (a) examine how families are involved in adolescent WT, (b) identify related outcomes and experiences of adolescents and families involved in WT, and (c) to provide further understanding of WT program and process theory. Research Objectives The following objectives guided the study: 1) To conduct qualitative inquiry to further understand the process and experience of family involvement in wilderness therapy;
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2) To conduct quantitative inquiry to identify adolescent outcomes, family outcomes, therapeutic alliances, and to explore their interrelationships; 3) To integrate the process and outcomes of family involvement in wilderness therapy to further articulate wilderness therapy program theory. Theoretical and Model Foundations The major theoretical frameworks guiding this study are (a) family systems theory (Becvar & Becvar, 1999) which posits that all members of a family contribute to, and are subsequently affected by each others actions simultaneously, (b) healthy family functioning (Walsh, 2003) which views and evaluates levels of family function through a strengths-based lens rather than a lens of dysfunction and deficit, and (c) the developing practice of wilderness therapy as defined and delivered by member programs of the Outdoor Behavioral Healthcare Industry Council (Russell & Hendee, 2000). Definitions Adventure therapy: A therapeutic modality combining therapeutic benefits of adventure experiences and activities with those of more traditional therapy (Bandoroff & Newes, 2004). Wilderness therapy is often described as a form of adventure therapy.
Alliance: Strength and quality of relationship between client and therapist (or person seeking change and change agent) based on agreements of goals, tasks, and bond (Horvath, 2001).
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Counseling: This level of engagement involves discussions and problem-solving between therapist and client in effort to resolve patterns of behavior or emotional discomfort (American Counseling Association, 2005).
Family: Parents, guardians, primary caregivers, and siblings that provide the basic social construction of family for the adolescent client (biological, adoptive, legal, cultural, and social (Dishion & Kavanagh, 2003).
Family functioning: Perceptions of strength and weakness within the family in areas of task accomplishment, role performance, communication, affective expression, involvement, control, and values and norms (Skinner, Steinhauer, & Sitarenios, 2000).
Outdoor behavioral healthcare: Programs in which adolescent participants enroll or are placed by parents or custodial authorities concerned for their well being; to change destructive, dysfunctional or problem behaviors exhibited by adolescents; through clinically supervised individual and group therapy, and an established program of educational and therapeutic activities in outdoor settings (Russell & Hendee, 2000).
Psycho-education: A level of engagement providing the client with programming or materials that explore and develop skills to reduce stressors, increase coping skills, and better understand their personal circumstances through the provision of emotional support, and education (Psycho-educational Research Training Centre, 2005).
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Psychotherapy: This level of engagement involves moving clients to address the effect of emotions and unconscious motivations on their dysfunctional behaviors (American Psychological Association, 2005).
Wilderness therapy: An adolescent treatment modality within adventure therapy which occurs exclusively in wilderness or similar locations and generally delivered in expeditionary style with inclusive groups and approximately 50 days in length (Russell, 2001).
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CHAPTER TWO: REVIEW OF RELATED LITERATURE Exploring Family Involvement in Adolescent Wilderness Therapy Theoretical bases, processes, and outcomes of adolescent wilderness therapy (WT) and family involvement in adolescent treatment literature will be reviewed, and recognized as critical in understanding their unique and related facets. The conceptual landscape explored for this study is the terrain where these two service delivery constructs converge and the theoretical framework of family systems theory which connects and integrates them. Consideration will be given to integrating and contrasting family involvement literature while recognizing limitations to full integration of families in current WT program models (Wells et al., 2004). This review will attempt to articulate a spectrum of family involvement in WT relative to more conventional models of family involvement in adolescent treatment. WT will first be located within the more broadly defined practice of adventure therapy and then further defined and described through specific WT literature. Brief overviews of outdoor behavioral healthcare (OBH) and existing WT research will be presented including limited research related to family involvement. A review of conceptual and theoretical origins of family-based therapy will be shared. Family-based adolescent intervention literature will then be presented to both inform and guide this study and the concepts of healthy family processes and the strengths-based approach will assist in the conceptual development of research methodology. As adolescents are the primary clients of OBH interventions, attention is given to adolescent mental health and substance use intervention literature. 10
Locating Wilderness Therapy within Adventure Therapy According to Bandoroff and Newes (2004), the field of adventure therapy is “coming of age” as a profession. Growth and development of the field has been closely aligned and integrated within other therapeutic disciplines with longer research histories and richer theoretical development (e.g., psychology, social work, and marriage and family therapy). Coupled with these foundations, adventure therapy has also attempted to maintain its uniqueness as a treatment modality. Adventure therapy generally involves some combination of challenge-based physical activity, experiential teaching and learning methodology, risk or uncertainty, and exposure to wilderness or outdoor environments (see Bandoroff & Newes, 2004; Gass, 1993; Gillen, 2003; Luckner & Nadler, 1997). A collective of therapeutic modalities are moving toward a generally accepted name to capture many program service delivery models utilizing these elements in different combinations. Currently, in the United States and to some degree internationally, the “field” has been termed adventure therapy (Gilbert, 2006). Although often described or discussed collectively within adventure therapy, WT is moving closer to a distinct, operationalized definition setting it apart from other treatment approaches (see Russell, 2001). While WT is the focus of this inquiry, the prevalent use of the term adventure therapy in literature will be reflected in this review and should be considered as inclusive of WT unless otherwise indicated. Attempts have been made to more accurately articulate distinct treatment approaches within the adventure therapy field including the following related models described in the literature: (a) adventure therapy (Gass, 1993; Gillis et al., 1992), (b) wilderness therapy (Davis-Berman & Berman, 1994; Russell, 2001), (c) wilderness 11
adventure therapy (Bandoroff, 1989; Crisp & Hinch, 2004; Weston & Tinsley, 1999), and (d) outdoor behavioral healthcare (Russell & Hendee, 2000) which utilizes WT. Wilderness Therapy Theory and Definitions Multiple definitions relating to WT have been integrated (Russell, 2001) to assist in furthering research and evaluation of WT theory, practices, and outcomes in a systematic manner. Davis-Berman and Berman (1994) defined WT as the administering of traditional therapeutic practices in the out-of-doors. The WT definition has been further clarified to more clearly set WT programs apart from wilderness experience programs (see Friese, Hendee, & Kinziger, 1998) sharing similar design but lacking qualification or intention to deliver therapy as recognized by licensed therapists in conventional practice. While located in wilderness or similar natural environments, WT has been articulated as possessing four key elements: (a) therapeutic intent, (b) clinical assessment and treatment planning, (c) facilitated by qualified and licensed therapists to evaluate progress, and (d) provision of therapeutic aftercare planning (Russell, 2001; Russell & Phillips-Miller, 2002). Adventure therapy defined in the larger field includes non-wilderness activities such as simulated adventure activities (i.e., challenge courses, initiative games, and climbing walls) and may even take place indoors (e.g., experiential activities in an office setting) (Crisp, 1998). Definitions of adventure therapy have been criticized for limiting the role or inclusion of wilderness as a therapeutic factor (Beringer, 2004). The question of whether WT can be conducted in non-wilderness (i.e., outdoors but not isolated) environments has not been thoroughly debated although some WT definitions have stated preferences one way or the other (see Russell, 2001). The criticism of the adventure 12
therapy field’s move away from inclusion of wilderness may be an indication of the inherent difficulties of defining and measuring the environment as a contributing factor in the therapeutic process. Another consideration for the exclusion of wilderness is the intentions of leading adventure therapy researchers and authors to more closely align their work with commonly accepted conventional therapeutic practices (i.e., psychology, social work, marriage and family therapy). Research in the field of social ecology has attempted to understand humanenvironment relations although the field has moved away from its biologicalgeographical origins to a social-cultural framework (Stokols, 1992). This conceptual shift parallels the present situation in WT in which more easily measurable factors (i.e., diagnosed emotional and behavioral disorders) are studied through empirical methods. In his work on health promotion and environmental quality, Stokols (1992) posited the need to utilize multi-faceted approaches in research, and to understand the diverse effects of the environment on individuals and groups. The role of wilderness in WT has yet to be fully understood and is underrepresented in current literature. Wilderness Therapy Process Attempts to develop a theoretical understanding of wilderness in the therapeutic process may not get beyond subjective interpretations due to a clear lack of observable, consistent, and measurable variables. Although research is beginning to address client change in WT through clinical measurement (Clark et al., 2004; Russell, 2003b), the element of wilderness as a therapeutic variable has not been substantiated theoretically (Russell & Farnum, 2004). While Beringer (2004) described the gaps in research attempting to understand the human-natural environment relationship in the therapeutic 13
process, Russell and Farnum (2004) proposed a concurrent WT model for research consideration. Integrating previous research supporting the psychological benefits of wilderness, the authors described the role of wilderness, the physical self, and the social self, as key factors for consideration in the development of a model of the WT process. Through qualitative analysis, the authors described key therapeutic factors of the wilderness environment that support the WT process. The following factors were identified through descriptive coding and were present in all four WT programs studied (a) appreciation of wilderness condition, (b) cleansing properties of nature, (c) absence of familiar culture, (d) reduction of distractions, (e) primitive lifestyle, (f) open spaces, and (g) the sense of vulnerability and humbling of being in the wilderness (p. 246). Long considered therapeutic, the role of wilderness in therapy is only now beginning to build an empirical base that could be validated through systematic research. Research in Adventure and Wilderness Therapy Meta-Analyses on the Effects of Adventure-based Programs Meta-analysis is a statistical procedure aggregating the results of existing studies and outcomes from similar research questions (Gall, Gall, & Borg, 2003). Meta-analysis has been used recently in an attempt to quantify the strength of a wide range of adventure-based programs in effecting participant change. Through meta-analysis of 96 studies, Hattie et al. (1997) outlined the strength and lasting effects that adventure programming can have on participants relative to other educational experiences with an overall effect size of 0.34. While many interventions included in this review were not defined as therapeutic, all studies included in the analysis were reporting intentional 14
efforts, and subsequent effect sizes, by programs to create participant change. Positive effect sizes (see Cohen, 1988) described in psychological literature and demonstrated in meta-analytic studies of adolescent treatment have been between 0.50 and 0.80 (i.e., a moderate effect) and is considered to be of a “respectable magnitude” (Weisz, Weiss, Han, Granger, & Morton, 1995, p.460). Hattie et al. (1997) concluded that adventure programs have shown “reasonably consistent” outcomes in the following categories: (a) independence, (b) confidence, (c) self-efficacy, (d) self-understanding, (e) assertiveness, (f) internal locus of control, and (g) decision-making. The authors tempered these positive findings by concluding that adventure program research is generally methodologically weak. The authors also reported many areas of adventure programming requiring further understanding and development including the need for theory development and process research to parallel outcomes research. Wilson and Lipsey (2000) meta-analyzed the effects of wilderness challenge programs on delinquent adolescents and concluded that “programs involving relatively intense physical activities or with therapeutic enhancements produced the greatest reductions in delinquent behavior” (p. 1). Similar to Hattie et al. (1997), the programs reviewed here were not identified specifically as therapy, although program intentions were to elicit participant change or therapeutic outcomes. Overall, the 28 programs included in this analysis revealed an effect size of just 0.18, therapeutic programs up to six weeks duration produced an effect size of 0.54 while longer residential programs (i.e., longer than six weeks) effect size was lower (0.2). The authors did, however, discuss the inability to differentiate the effects of program duration and activity intensity, further supporting the need for process research. 15
Hans (2000) utilized meta-analysis to address the effect adventure programming has on locus of control specifically. Not surprising, Hans identified programs purporting to be “therapeutic” achieving higher effect sizes overall (0.64) vs. education and prevention programs (0.35) or adjunctive programs (0.30). The author also described residential programs showing higher effect sizes than outpatient settings (0.4 vs. 0.2) and a mixed category (i.e., both residential and outpatient settings) demonstrated an even higher effect size (0.54) suggesting the potential for increased effects through integrating learning in programs with life at home. A summary of meta-analyses conducted by Neill (2003) compared outdoor education, psychotherapeutic interventions, and innovative educational practices to establish a benchmark for ideal client effect sizes (i.e., measurable amount of change toward desired state) in adventure therapy programs. Outdoor education programs were found to have greater effect sizes than innovative educational practices in producing change; however, they were not as effective as psychotherapeutic interventions. These results suggest further room for improvement in the design and delivery of effective outdoor programs with therapeutic goals. To that end, Neill also expressed the need for the adventure therapy field to conduct sound, empirical research with commonly accepted therapeutic program descriptions and measures. Further research issues in adventure and WT will be covered in Chapter Three. Limitations of Current Knowledge Research and evaluation in WT and other adventure-based programming has been consistently challenged for numerous reasons including (a) lack of a research base (Gass, 1993), (b) high diversity of programming (Hattie et al., 1997), (c) not addressing 16
specificity in variables (Hans, 2000), (d) overemphasis on outcomes without specifying processes responsible for change (Baldwin, Persing, & Magnuson, 2004), (e) lack of valid methods of comparison (Neill, 2003), (f) lack of control groups (Newes, 2001), (g) limited follow-up or long term research (Bandoroff & Scherer, 1994), and (h) as being self-selective and a self-fulfilling prophecy (Bocarro & Richards, 1998). In suggesting methods and research designs for adventure therapy from a psychotherapeutic perspective Newes (2001) stated: Without the implementation of tighter control we have neither internal nor external validity, and the best we can say is that some AT [adventure therapy] programs may simply have some effect at a particular moment in time (p. 99)
Research has, however, demonstrated positive outcomes in adventure programming and is moving toward a more theoretical and process-based understanding (Hattie et al., 1997). Baldwin et al. (2004) have suggested a research approach to address theory, process, and outcomes as an alternate approach to understanding how, and if, programs work. This approach does not subscribe to empirical practices but may be well suited to adventure programming. The authors described the use of theoretical models on which to build programs and conduct outcomes evaluation. This in turn leads to richer understanding of how programs work and can assist the researcher in understanding process pieces—looking into the “black box” of programs as it has been termed— possibly causing change in program participants. The authors recommend more complete integration of theoretical understanding into program design, practices, and evaluation
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“so that well designed evaluations may serve as optimal empirical tests of theory” (p. 177). Empirical Support from Other Fields Research drawn from environmental science and psychology is providing current, empirical, and contextual support for wilderness experiences in the therapeutic process. Two key elements found to contribute to positive outcomes are (a) natural outdoor environments, and (b) physical activity. In a nationwide study involving 451 parents of children with Attention Deficit Hyperactivity Disorder (ADHD), Kuo and Faber Taylor (2004) found that outdoor environments appear to contribute to reductions in ADHD symptoms across all demographic and case characteristics studied. The authors concluded that physical activities conducted in “green” natural environments were significantly more effective than those conducted in indoor environments and are here reasoned to be closely aligned with utilization of outdoor activities and environments in WT and related symptom reduction (Russell, 1999; 2003b). Additionally, Wells and Evans (2003) found children living closer to nature as having lower levels psychological stress, and that nature was shown to moderate stress on a child’s perception of self worth. Clinical psychologists Read and Brown (2003) reviewed literature and current research supporting the role of physical exercise in improving mental health outcomes for persons with alcohol use disorders. The authors concluded that physical exercise is a promising and viable substance abuse intervention and suggested it for clinical application and recommended further empirical research to demonstrate effectiveness. A recent randomized trial combining peer-based adventure therapy programming with
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cognitive-behavioral treatment for obese adolescents has also demonstrated superior outcomes (Jelalian, Mehlenbeck, Lloyd-Richardson, Birmaher, & Wing, 2006). The use of outdoor settings and physical exercise depicted in these studies parallel two original tenants (i.e., unique physical environment and challenge-based activity) of the Outward Bound program model (see Walsh & Golins, 1976) which is widely accepted as a key theoretical source in adventure-based programming and adventure therapy. Wilderness and adventure therapy research has only begun to address these two central factors in a rigorous and comprehensive manner to enhance the understanding of the role that nature and physical exercise play in the therapeutic process (Harper & Scott, 2006). Wilderness Adventure Therapy Bandoroff (1989) was one of the first to use the term wilderness adventure therapy (WAT) which is currently being used in a manualized treatment format in Australia (Crisp, 1998). Crisp and Hinch (2004) evaluated WAT for adolescents and concluded that it was more effective and required shorter treatment duration than comparative outcome studies of conventional modalities. The study included 39 Australian adolescents who were not responding to traditional therapy and 36 specifically described as “at-risk.” Outcomes included significant reductions in mental health symptoms including depression and suicidal behavior that were coupled with an increase in protective factors including self-esteem, social competence, and family functioning. The authors suggested that the WAT program studied was an effective intervention compared to conventional adolescent treatment. Two notable strengths of this study were the utilization of reliable instrumentation with excellent psychometric properties and a 19
standardized treatment protocol. Although deemed promising for adolescent treatment, the findings of this study have yet to withstand the process of peer review and publication in mental health journals, was conducted without comparison or control groups and a small sample (N = 39). Similar interventions in adolescent wilderness treatment have been evaluated in the United States primarily within the program members of the OBH Research Cooperative. Research in Outdoor Behavioral Healthcare Outdoor behavioral healthcare (OBH), a service delivery model in the United States, utilizes wilderness therapy (WT) in their work with adolescents with emotional, psychological, behavioral and substance use disorders (Russell & Phillips-Miller, 2002). With over 100 programs in the United States, OBH programs vary in length, definition, and practice but are described collectively by Russell and Hendee (2000) as: Programs in which adolescent participants enroll or are placed by parents or custodial authorities concerned for their well being; to change destructive, dysfunctional or problem behaviors exhibited by adolescents; through clinically supervised individual and group therapy, and an established program of educational and therapeutic activities in outdoor settings (p. 8)
Adolescents attending OBH programs may enter either through adjudication (i.e., placed by authorities) or private placement and partake in one of the five following program models: (a) Contained Expedition, (b) Continuous Flow Expedition, (c) Base Camp Expedition, (d) Residential Expedition (Russell, 2003b) or (e) Outpatient Expedition (Russell, 2006b). These classifications denote the length of time adolescents 20
spend in a particular program, the length of field or wilderness exposure, and the clinical aspects of programming including time spent with therapists and level of involvement with parents and families. It is recognized that although similar, programs vary in theory and process (Russell & Phillips-Miller, 2002). Systematic OBH Research to Date Basic definitions of treatment models in OBH were established in efforts to distinguish these clinical treatment models from other wilderness experience programs (Russell & Hendee, 2000). An outcome study was conducted in which a cohort was followed for twelve and twenty-four months and outcomes reported included qualitative and quantitative results (Russell, 2003b, 2005; Russell & Phillips-Miller, 2002). A sustained research agenda has been established within an industry-driven research cooperative lead by Russell (OBHRC, Outdoor Behavioral Healthcare Research Cooperative) and housed at the University of Minnesota in the College of Education and Human Development. The Youth Outcome Questionnaire (YOQ) was administered by Russell (2003b) to both adolescents attending one of seven participating OBH treatment programs and their parents. The YOQ was employed at admission and discharge from treatment with 523 adolescents and 372 parents, and again at 12-months post-discharge with a random sample of over 200 including both adolescent self-report and parental assessment of adolescents. This 64 item instrument measures psychological and social functioning in six content areas: (a) interpersonal distress, (b) somatic, (c) interpersonal relations, (d) critical items, (e) social problems, and (f) behavioral dysfunction (Burlingame, Lambert, Reisenger, Neff, & Mosier, 1995). Outcomes reported significant reductions in YOQ 21
scores pre-treatment to post-treatment across all ages, from both adolescent and parental reports, and across a range of clinical diagnoses indicated by the Diagnostic Statistical Manual for Mental Health Disorders 4th Ed. (DSM-IV) (American Psychiatric Association, 1994). Of note, YOQ score reductions were greater in continuous flow expedition programs (i.e., 8 weeks in duration) than shorter programs. Adolescent and parental YOQ reports at 12-months post-discharge indicated both maintenance and further reduction in scores. This finding is in contrast with reviews of general adventurebased program outcomes showing favorable effects fading with time following programs (see Hattie et al., 1997). Overall, the 12-month outcomes supported significant reductions in adolescent emotional and behavioral symptoms and maintenance of the positive effects a year post-discharge from treatment. Russell continued the study with a 24-month follow-up (Russell, 2005). Parents and adolescents were contacted to identify (a) how well the adolescents were doing, (b) what was the role of aftercare, and (c) whether the OBH experience was worthwhile. The researcher utilized phone interviews to assess the transition from treatment to aftercare as well as longitudinal outcomes of adolescent participants. Eighty percent of parents (n = 88) and 95% of adolescents (n = 47) perceived OBH treatment as effective and parents reported adolescents as “doing well” (58%) “not doing well” (28%) and doing “better than before” (14%). Although reports of continued emotional and behavioral difficulties existed, both parents and adolescents described the WT intervention as necessary and worthwhile in breaking a pattern of destructive behaviors. It is critical to note here that 85% of the adolescents involved in this study utilized some form of aftercare services
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(i.e., residential or outpatient services) depicting the role of OBH as one element in a mental health “continuum of care.” Due to length of time adolescents participate in WT programs (i.e., 50 days on average), parents and families are strongly encouraged to participate in the treatment process. Many OBH WT programs do not accept adolescents if the family is not willing to take an active role in the process (Russell, 2000). Russell described a primary goal of WT programs as trying to strengthen the family system from which the adolescent came and to which they will eventually return. Clinical teams employ numerous techniques and program practices to engage families in recognizing the potential dysfunction of the family system and to re-establish healthy family structure for the adolescent’s return. WT program research in OBH has primarily concentrated on adolescent outcomes, though parental involvement in OBH programs was suggested to lead to positive effects (i.e., bringing family together, seeing adolescents differently, and improved parenting skills) and ultimately result in strengthening the family (Russell, 1999). The suggestion of family involvement presupposed the need for family support following termination of treatment and the adolescent’s inevitable return home. Russell (2005) described postprogram transition and aftercare services as critical in the adolescent treatment process; his qualitative follow-up on the cohort two years after treatment provided a snapshot of overall effect of program on the family unit. With both parents and adolescents rating the OBH intervention as a catalyst to behavioral and emotional change, the whole family was reasoned to benefit from the WT intervention. Clark et al. (2004) have completed the most clinically significant research in WT to date. This multi-dimensional study addressed three of the five axes of the DSM-IV 23
(American Psychiatric Association, 1994) used in psychological and mental health fields to identify mental disorders. One hundred and nine adolescents participating in 21-day programs of one WT program were included in this study. Significant positive outcomes were reported for many mental disorders with special attention being given to characterological change as it is rarely affected by short term interventions. This finding is suggested by the authors to have long reaching implications considering the negative impact personality disorders have on individuals, families and society. While this study provides another formal step toward recognition of WT in psychological and psychiatric research fields, a lack of control or comparison groups was present, no follow-up was completed, and the study was limited to those choosing to participate at one WT program. These methodological issues severely limit generalizability of the findings. Descriptive Analysis of Family Involvement in OBHRC Member Programs Harper (2005) conducted a survey of ten OBHRC member programs to assess the format, duration, and type of therapeutic intervention with client families during adolescent WT treatment. Results indicated that (a) most programs expressed mandatory parental involvement, (b) programs assess and include family goals in treatment, (c) most describe utilizing a counseling/supportive and psycho-educational approach with families, (d) remote family contact ranged from ten hours each week (40%) to ten-thirty hours each week (60%) and (e) 90% utilize letter writing, therapist-parent phone calls and direct family participation in certain program elements (generally at client admission and discharge). Additionally, (f) family inclusion in programming includes some combination of conjoint, separate or multi-family format, (g) programs collaborate with parents in planning aftercare and the post-treatment transition, and (h) that follow-up 24
efforts with clients and families ranged from no contact (30%) to periodic contact for more than six months (30%). While demonstrating fairly high consistency in family-related practices, these ten OBHRC programs do not however, represent the philosophies or practices of all adolescent WT programs. Further, while OBHRC intends to contribute to the positive development of the entire OBH industry through research and contributing to the development of industry standards, only two of these programs will be utilized in this study. Families and Therapeutic Wilderness Programs Regardless of approach, it has been suggested that individual and family therapy techniques can be synthesized if the intention of the therapy aligns with the family’s goals (Selekman, 1997). WT programs may prefer—or be limited to—family involvement rather than family therapy. This is a critical difference between adolescent WT and family wilderness therapy (Bandoroff, 1992). Although OBH programs in this study focus primarily on adolescent treatment, they do involve and support the family through numerous intentional practices as previously stated (Harper, 2005; Russell, 2001). This distinction may provide advantages for the clinical team in addressing family issues in a direct and non-clinical manner (i.e., advising needed family change) rather than working with the family in therapy bound by roles and expectations of the clienttherapist relationship. Family perception of their responsibility to the change process may also be at question when only the adolescent is considered in treatment (i.e., therapy) while the family is not explicitly in therapy.
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Research on inclusive family involvement in WT is limited. The few studies conducted suggest positive benefits in family communication (Huff, Widmer, McCoy, & Hill, 2003), collective efficacy (Wells et al., 2004), and healthy family functioning (Bandoroff & Scherer, 1994) although long term maintenance of change has not been supported (e.g., see Pommier & Witt, 1995). Wells et al. (2004) examined the collectiveefficacy of families with at-risk adolescents participating in four day wilderness challenge activities. Although described as challenge-based recreation, the treatment was delivered by a WT program. Collective efficacy was defined as an individual’s perceptions of a group’s ability to perform tasks together. Rather than changing behaviors, collective efficacy was achieved through changing beliefs regarding personal and group (in this case family) abilities. Twenty-three families participated in one of three wilderness activities (different levels of difficulty) and two customized measures were used to assess changes in collective efficacy and conflict resolution outcomes. Results showed collective efficacy increased in all three treatment groups providing support for their hypotheses that these increases would then positively affect the family’s ability to resolve conflict. The construct of parent-adolescent communication was also addressed in this study. Huff et al. (2003) administered a relationship/communication instrument to measure families participating in the wilderness challenge activities and found positive increases in all three treatment groups. It is critical to remind the reader that these two studies, although conducted in collaboration with a WT program with at-risk adolescents and their families, did not presuppose therapeutic intent. The programming would be described as psycho-educational with family support and positive reinforcement, and may 26
result in therapeutic outcomes. Wilderness experience programs have long provided opportunities for personal growth and development but clear distinctions have been made to ensure the consumer is well aware of the programs abilities and intended outcomes such as adolescent treatment within a recognized, licensed rehabilitation program (Russell & Hendee, 2000). Pommier and Witt (1995) evaluated levels of family functioning during an Outward Bound School 30-day program for juvenile status adolescents which included family training components. Results showed significant pre-treatment to post-treatment improvements had deteriorated at three-months post-treatment. Family involvement included workshops and conferences on interpersonal and social skills for parents, and at times, parents and adolescents, throughout the month-long intervention. The evaluation of this educational wilderness approach (delivered by non-therapeutically trained staff) provides an example of family involvement efforts being diminished following the return of the adolescent to their everyday family, school and community life. Bandoroff and Scherer (1994) designed and assessed Family Wilderness Therapy (FWT) in a program format similar to many OBH programs but with two main distinctions: (a) adolescents came off a 21-day WT program and were joined by their families for a four-day family therapy intervention, and (b) the presence of therapeutic intent (i.e., family therapy) to re-integrate the adolescents with the family as the primary focus of the experience. Twenty-seven families participated in the FWT treatment group and quantitative scores following the intervention had moved from “clinical” to “normal” levels in healthy family functioning as measured by the FAM instrument. Sample homogeneity and self-selection were both described as limitations to this study. The 27
work of Bandoroff and Scherer provides a basis for theoretical and methodological considerations for this study in that similar measures and program models will be assessed. The authors described limitations of research design and methods in family WT settings including “remoteness of program site, the advance notice required by participating families and our inability to offer unselected families an alternative treatment” (p. 181). Family Involvement in Adventure Therapy The larger conceptual field of adventure therapy (AT) has marginally more research than WT specifically. This review of family-related adventure therapy offers further insight related to family involvement in WT and will include (a) types of family involvement in AT, (b) depth of intervention in AT, and (c) comparative examples of family involvement in AT and WT. AT activities are not generally conducted in wilderness environments, although the difficulties in logistics and the cost-preventative nature of multi-day family programming still exist. A survey in the early 1990’s showed almost 85% of 44 programs surveyed provided adventure therapy sessions between one hour and a full day; however 90% of these programs worked primarily with multiple family groups and were located in hospitals or treatment centers (Gillis et al., 1992). Although all programs reported working with families, they were described as approaching family work with varying levels of intensity and therapeutic intent. Gillis et al. (1992) derived four categories of intervention based on intent, level, and duration of intervention. Table 1 depicts the levels of intervention as: (a) recreation,
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(b) enrichment (psycho-educational), (c) adjunctive, and (d) primary therapy as well as the corresponding relationships to therapy, duration and example activities. Table 1. Depth of intervention in adventure therapy: Relationship to treatment, duration and examples Recreation Relationship to Fun, rejuvenating treatment experience, may increase quality of life
Enrichment
Adjunct
Primary
Educational, may learn skills helpful in treatment
Actively supports attainment of treatment goals
Treatment
Duration
May be a single Structured session, short as sessions, one hour multiple days
Structured, one- Usually four days multiple sessions
Example
Activities or initiatives without “enjoyment” as intended outcome
Activities aimed at assisting in client or family change processes
Activities aimed at building resources and knowledge acquisition
Activities aimed at discovering underlying issues causing dysfunction
This framework has been referred to as the depth of intervention in adventure education and therapy literature (Ringer & Gillis, 1995). The authors presented the framework to assist practitioners in facilitating groups within their appropriate levels of training and to heighten awareness of when they may have moved from one “depth” to another. In reviewing AT literature, Burg (2001) described diversity in programming and the level and type of intervention used by programs as limiting factors in generalizing research findings. Limited literature exists to inform ideal and effective type or depth of family involvement in WT. Five examples from the literature are presented in Table 2
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and represent the diversity of family involvement in AT and WT treatment, including modalities and durations. Table 2. Examples of family involvement in adventure therapy literature: Definitions, modality, depth and duration of intervention Author (s)
Name
Family definition
Modalities
Depth
Duration
Clapp & Rudolf
The Family Challenge Program
Those with emotional ties and living with identified client
-assessment -enrichment -adjunct
-five sessions over three week period
Gass (1993)
Adventure Family Therapy
Not defined but appears to be inclusive of all family members capable of participating
-MultiFamily -Experiential Learning -Adventurechallenge, team building activities -Structural -Strategic -Experiential Learning -Adventure challenge, initiatives
-assessment -adjunct -primary
Bandoroff & Scherer (1994)
The Family Wheel program
Parents and identified client
-Structural -MultiFamily -Wilderness skills/ travel
-adjunct -primary -family enrichment
Pommier & Witt, (1995)
Outward Bound with Family Training Program
Adolescent treatment (juvenile status offenders) Parental involvement
-MultiFamily -educational approaches -counseling
-enrichment -adjunctive to justice system
-not described but appears to be used in sessions aligned with conventional therapy practice -family joins adolescent client for four days following 21-day trek -family separate and inclusive through 30day intervention with followup
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Author (s)
Name
Family Definition
Modalities
Depth
Duration
Russell (1999)
Outdoor Behavioral Healthcare Programs
Primarily adolescent treatment Parental involvement
-assessment -adjunct -primary
-50 days average adolescent treatment
Huff, Widmer, McCoy, & Hill (2003)
Challenging Outdoor Recreation
Parents, siblings and identified client
-Eclectic approaches, program dependent -Wilderness skills/travel -Wilderness skills and travel
-recreation -assessment
-4 day inclusive family experience
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Family Involvement in Adolescent Treatment: Theoretical Framework, Process, and Outcomes The final section of this review explores family involvement in adolescent treatment in general and focuses on (a) family systems as the theoretical and basis of family therapy and family involvement in adolescent treatment, (b) support for the shift from individual to family approaches, (c) the conceptual frameworks of normal family processes and strengths-based approaches, and (d) research supporting the integration of families in adolescent treatment. The review concludes with an exploration of (e) multiple dimensions of family engagement including levels of therapeutic intervention and family involvement formats, and (f) the construct of working alliance as related to family involvement in adolescent treatment. Family Systems Theory Systems and the Change Process In a response to growing scientific reductionism, Bertalanffy (1968) introduced general system theory to re-engage science and scientists in a holistic, unified way. The result was a significant impact on the thinking of social scientists ranging from psychiatrists to communication experts and was seen as a catalyst in the growth of research and application of systems theory (Broderick, 1993). Anthropologist Gregory Bateson is recognized as a leading contributor to the development of systems thinking in social sciences, and more specifically the application of systems theory to therapeutic interventions (Broderick, 1993). Bateson also integrated cybernetic theory (i.e., process of feedback and self-correction within systems first 32
described by Wiener, 1965) into the realm of family processes (Watzlawick, Weakland, & Fisch, 1974) which have become common and accepted as theoretically guiding process elements of systemic therapeutic practices. Understanding change in the family system will be critical in the evaluation of OBH programs and it relationship to adolescent change previously reported. In discussing the cybernetic theory of self-regulation related to the human system, Wilcoxon (1985) stated “As with any system, attempts to alter one component [or member] in a family system will typically elicit resistance from other members until a new pattern is established by mutual adjustment” (p. 495). Watzlawick et al. (1974) recognized the need for these two patterns—persistence and change—to be considered together when working with families. Becvar and Becvar (1999) went so far as to suggest that it is unreasonable to ask an individual within a system to change and to not address the system that maintains it or possibly contributes to the presenting issue. Regardless of the composition or definition of a family, the family is a human system and experiences interaction among it members. Further, the realities of child and adolescent development, heightened by emotional and behavioral problems, create diverse and often unpredictable family dynamic. Ultimately, therapists and researchers must consider the reality of attempting change at the individual level, and change with other members of the family system, as separate but related processes. Healthy Family Functioning A shift occurred in the 1980’s away from deficit-based (i.e., representing a relatively unsuccessful pathology-driven approach to therapy) to strength-based language 33
and practice producing the terms healthy, functional, and typical as they relate to families (Walsh, 2003). Walsh described deficit-based language as still common due to prevalence of psychiatric and medical models which identify individual or family dysfunction, illness or disorder that is “not normal.” Through the lens of healthy family functioning (Wilcoxon, 1985) which recognizes the systemic nature of families and family change through life stages, family strengths has been suggested as a unit of measurement rather than pathology. This approach recognizes change and growth in family functioning and utilizes related psychometric instrumentation which is based on deviation from a perceived norm of ideal family strengths (Early, 2001). The implications of recognizing healthy family functioning within a family system perspective is critical in the assessment and intervention processes of family-based therapeutic interventions (Wilcoxon, 1985). The design of family measures from a strengths perspective acknowledges family competence and provides the opportunity for empowerment in the treatment process (Saleebey, 1997). In an overview of normal family processes, Walsh (2003) described normal as being socially constructed and warned of the definition’s ability to stigmatize, prejudice, and influence clinical theory and practice. Important to this conception of normal family process is the reality that normal families have elements of dysfunction—they also have the capacity to deal with their problems in healthy ways (Minuchin, 1974). Gender, cultural diversity, socioeconomic disparity, and the family life cycle are key factors which would eclipse any efforts to define “normal” and need to be strongly considered in family therapy and research.
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The Family Defined For the purpose of this study the researcher has adapted partial definitions of family are culled from the literature to form a unique definition for this study. Kumpfer (1999) defined family as “the basic institution of society primarily responsible for childrearing functions…[and] is responsible for providing physical necessities, emotional support, learning opportunities, moral guidance, and building self esteem and resilience.” (p. 18). Liddle (1996) broadens the definition of family to include extra familial subsystems participating in the child’s life to increase potential therapeutic outcomes. The author goes on to describe multidimensional, multisystemic approaches strategically including as many family and extra familial individuals in to the therapeutic process as advantageous. Last, since children are exposed to a wide range of family and interpersonal dynamics, the following definition will assist in guiding this study from an inclusive and ecological approach, attempting to recognize the potential diversity of families, or as Dishion and Kavanagh (2003) describe, the child’s “primary socialization agents.” (p. 11). For the purposes of this study, family will be defined as parents, guardians, primary caregivers, and siblings that provide the basic social construction of family for the adolescent client (biological, adoptive, legal, cultural, and social). While recognizing the benefits of involving other community and extra-familial individuals within the definition and the treatment process, limits need to be drawn for practical application.
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Empirical Support for Family Involvement in Adolescent Treatment Family-oriented interventions have become most prevalent in the fields of child psychotherapy, adolescent psychiatric treatment, delinquency prevention, child protection, and school-based counseling (Crampton, 2004; Fauber & Long, 1991; Kraus, 1998; Kumpfer, 1999; Leitchman, Leitchman, Barber, & Neese, 2001; Vanderbleek, 2004). Specifically, current research demonstrates positive outcomes of family involvement in child and adolescent treatment of anorexia nervosa, bi-polar disorder, social phobia, challenging behavior, substance abuse, depression, and anxiety disorders (Crampton, 2004; Diamond et al., 2003; Eisler et al., 2000; Hirshfeld-Becker & Biederman, 2002; Kashdan & Herbert, 2001; Kerr et al., 2003; Klein et al., 2003; Leichtman et al., 2001; Lewis, Piercy, Sprenkle, & Trepple, 1990; Rea et al., 2003; Spence, Donovan, & Brechman-Toussaint, 2000). A recent study with Latino adolescents showed familial connectedness and parental monitoring as the strongest predictors for deterring risk-related behaviors associated with drugs and alcohol (Kerr et al., 2003). Multi-family interventions encouraging interfamily group process were shown to reduce drug use, improve academic achievement, and improve pro-social and family functioning more successfully than individual adolescent therapy or psycho-educational family interventions (Liddle et al., 2001). Although not statistically significant, a direct comparison between individual and family treatment showed the family intervention of childhood social phobia producing superior results to the child-only intervention (Spence et al., 2000).
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Types of Family Involvement Additionally, a number of comparative studies have sought to determine levels of effectiveness between conjoint (i.e., whole family) and separate (i.e., identified client seen separately from family) treatment modalities. Of note, controlled trials studying adolescent anorexia nervosa (Eisler et al., 2000; Robin et al., 1995) showed both modalities positively affected family functioning and decreased symptoms in adolescent clients. Descriptions of outcomes in both studies clearly support and encourage family involvement but do not indicate overall greater efficacy of conjoint or separate family treatment. Although primarily working with females in small and homogenous samples, these findings have provided insight into what variables and conditions could be addressed when working with family-based interventions. Although not statistically significant, Eisler et al. found more improvement in cognitive and emotional outcomes (e.g., mood, obsessionality) with conjoint family therapy while separate family therapy produced greater behavioral outcomes (e.g., weight gain, nutritional status). Further, a study of cognitive behavioral treatment of children with social phobia showed statistical and clinical significance in treatment both with and without parental involvement, although a trend toward superior outcome existed when parents were involved (Spence et al., 2000). Although conducted on clients with diagnoses from the DSM-IV (American Psychiatric Association, 1994) the treatment in this study was considered a psychoeducational skills training program rather than a psychotherapeutic intervention. Family-oriented practices are integrating families in multiple processes, reflecting a family systems approach and continue to refine practice through an increasingly diverse and developmental research agenda (Cunningham & Henggeler, 1999; Liddle et al., 37
2000). Leichtman et al. (2001) suggest building a base of support in the community as well as the family and place emphasis on discharge planning as these additional factors demonstrated post-treatment success from short-term residential interventions. Residential treatment programs have also explored the use of remote treatment practices to include families when challenged logistically (Springer & Stahmann, 1998). The use of telephones in residential treatment was reviewed through administration of a customized 21-item self-report instrument with 47 parents of adolescents in treatment. Parents experienced both conjoint and separate family therapy through phone communication with program therapists. Effectiveness in family communication and functioning were positively reported lending support to the use of remote (e.g., telephone) therapy in meeting the demand for increased family involvement in residential programs. This extension of traditional therapeutic practices is of importance considering the physical distances families will be from their adolescents during WT programs. A family strengthening approach aimed at improving parenting practices has been described as a key strategy in reducing adolescent drug use/ misuse, delinquency, and emotional and behavioral problems (Kumpfer, 1999; Kumpfer et al., 2003). In a report for the Office of Juvenile Justice and Delinquency Prevention, Kumpfer et al. (2003) posited that although family approaches show larger effect sizes than child-only interventions, combining both approaches in a comprehensive program will yield the best results. This multidimensional family approach has also shown superior outcomes over adolescent group therapy and multi-family educational interventions in adolescent drug and alcohol treatment (Liddle et al., 2001).
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Literature describes family involvement strategies in a number of ways in adolescent treatment of emotional and behavioral disorders. Through synthesis of this literature, family involvement is described in this study in the following ways: (a) levels of therapeutic engagement, (b) formats of family involvement, and (c) considerations for the working alliance. The following descriptions will assist in clarifying types of family involvement in adolescent treatment in addition to providing a conceptual frame to guide this study. Levels of Therapeutic Engagement The following definitions from the Substance Abuse and Mental Health Service Administration (SAMHSA, 2005) provide an overview of alternate approaches to working with clients and families. Potential levels or depth of engagement a program may choose to use when working with adolescent clients and their respective families are expressed. Each definition is followed by an example from related wilderness and adventure therapy practices. These three levels of therapeutic intervention are placed in order of depth relative to psychological engagement and levels of training required by program staff to safely and ethically conduct. However, it is assumed here that practitioners may therapeutically engage clients and their families in multiple ways based on assessed needs. Psycho-educational This level of engagement provides the client with programming or materials that explore and develop skills to reduce stress, increase coping skills, and better understand their personal circumstances through the provision of emotional support, and education. 39
For example, many adolescent WT programs engage parents in on-line parenting workshops where parents complete workbooks and discuss their progress with a program therapist remotely (i.e., not face-to-face) in addition to a program website allowing for continued support through a technological medium. Although not governed or overseen by a professional body, psycho-education practices call on both the counseling and educational settings to further improve practice and disseminate knowledge. While early in its inevitable growth to becoming a stand-alone discipline, some researchers are dedicated to this collaborative effort between well established fields such as the Psycho Educational Research Training Center (see PRTC, 2005). Counseling This level of engagement involves discussions and problem-solving between therapist and client in effort to resolve ineffective patterns of behavior or emotional discomfort. Some forms of counseling are considered therapy as depicted in the following definition. Counseling focuses on providing the client with the opportunity to improve their own situation (i.e., generally mental health). For example, some adventure therapists work with intact families and focus on enriching the family-dynamic. In this scenario, the therapist facilitates the experience while the family works on issues as they arise and thereby improve their skills (e.g., communication, conflict resolution). Professional organizations provide counselors with accreditation and professional and ethical guidelines such as the American Counseling Association (see ACA, 2005).
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Psychotherapy Based on the principles of psychoanalysis, psychotherapy engages clients at a level to address the effect of emotions and unconscious motivations on client behavior. Psychotherapy is steeped in the premise that one’s behaviors are strongly influenced by past experience, present concerns, and genetics. An example of psychotherapy is a WT program that utilizes a licensed psychotherapist to engage adolescents in understanding and addressing where their behaviors come from and collaboratively plan how to reduce or eliminate inappropriate behaviors or beliefs. Professional practices are also accredited and reviewed by professional organizations such as the American Psychological Association (APA) (2005). Family Involvement Types The format that family involvement can take in therapeutic interventions is summarized in the following four ways: (a) conjoint, (b) separate, (c) multi-family, and (d) multi-dimensional/multi-systemic. Conjoint family therapy is described as being “inclusive” of the client and the family. As the term family may constitute a variety of forms, this definition is incomplete. It would be fair to assume however that the conjoint family therapy would include the identified client and members of the client’s family as well as significant people involved in the client’s life. Separate family therapy is described by the client and the family attending therapy at different times in addition to meeting collectively. This model of therapy has been
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seen in child and adolescent therapy and often integrated with conjoint practices allowing the therapist time with the client, the family, and often, the parents separately. Although fairly self-explanatory, multi-family therapy may manifest in many forms. Depending on family make-up or levels of family participation, a multi-family therapy group may have a few to many families depending on numbers. One primary goal of the multi-family format is to use peers (i.e., other families) to both normalize family experiences as well as assist in the intervention. A multi-dimensional/multi-systemic approach has been depicted in literature as a dynamic approach to adolescent interventions engaging individuals, groups and community resources to meet client needs (Dishion & Kavanagh, 2003; Liddle et al., 2001). Key principles of the multi-dimensional approach are the extension of the traditional client-therapist relationship to include members of ones community, friends, and extended family. This approach is driven by the belief that the breadth of social support and depth of intervention needs to match client needs and adjust accordingly. Regardless of program or therapist orientation, a significant in-treatment consideration is given to a working relationship that can be established to increase opportunities for positive outcomes in all forms of treatment. The following section describes the working alliance. The Working Alliance Predictor of Outcomes One of the most consistent predictors of psychotherapeutic outcomes is the alliance formed between therapist and client (Barber, Connolly, Crits-Christoph, Gladis, 42
& Siqueland, 2000; Horvath, 2001; Martin, Garske, & Davis, 2000). This working or therapeutic alliance is determined by the strength and quality of the collaborative relationship between client and therapist (Horvath, 2001) and built conceptually on the constructs of goals, tasks, and bond (Bordin, 1979; Diamond et al., 2000; Horvath & Symonds, 1991). Simply put, the client and therapist work more effectively if they agree on (a) what the client needs to achieve (i.e., goals), (b) how the goal will be achieved (i.e., tasks), and (c) the quality of the relationship (i.e., bond or attachment). Alliance and the Family Treatment fidelity and satisfaction with therapeutic services have also shown to directly relate to working alliances in studies involving parents in adolescent therapy (Hawley & Weisz, 2005). Diamond et al. (2000) described the need for parents to build an alliance with therapists to act as intermediaries in treating adolescents through increased involvement and investment in outcomes. The authors propose an alliance be established with parents prior to focusing on adolescent pathology to ensure parents feel understood and supported thereby increasing the potential for positive outcomes. Stronger early treatment alliances developed with therapists have been shown to predict reductions in adolescent drug use and externalizing behavioral problems (Hogue, Dauber, Stambaugh, Cecero, & Liddle, 2006). Parent and adolescent therapeutic alliance in a large-scale experiment for adolescents with substance abuse issues demonstrated strong support for the inclusion of families in the treatment process (Shelef, Diamond, Diamond, & Liddle, 2005). The authors found early adolescent-therapist alliance predicts treatment outcomes, adolescent-therapist alliance and parent-therapist alliance predicts treatment 43
completion and effectiveness of treatment, and further suggest that parent-alliance may be a mediating factor in the formation of stronger adolescent alliances, which assists in maintaining long-term outcomes. Summary of Literature Reviewed This literature review has explored family involvement in the adolescent treatment programs of OBH utilizing WT, and has specifically integrated literature in family systems theory, family involvement in adolescent treatment, the working alliance, and research and practice of WT. This review tells us that (a) family involvement in adolescent treatment is critical in producing more significant outcomes, (b) WT is increasingly utilized as a treatment modality for high risk/high needs adolescents, (c) WT has begun to demonstrate promising outcomes yet lacking clear theoretical understanding and empirical support, and (d) while recognized as a key facet to successful adolescent treatment, family involvement in WT is limited by realities of cost and logistical difficulties. While WT programs espouse a family systems approach, it remains unclear how to most effectively involve families in the treatment process. WT and related literature has been often criticized for methodologically weak studies—the bleak reality of conducting research in notoriously difficult situations and can be reasoned to be more difficult when working with clinical clientele and families in crisis. The intensive and isolated nature of WT programming creates logistical difficulties while service provision is without waitlists or intake deferral removing possibilities of randomization and control group research. Further, as WT programs adopt a family systems perspective, family involvement practices are not without their own cost and logistical barriers. Understanding what current WT family involvement 44
practices are effective, and where improvement needs to be made to increase potential positive change in the family system, is needed to better serve adolescent clients. Family involvement in adolescent treatment literature indicates that (a) family involvement is superior to none, (b) family involvement may take numerous forms, and (c) that limited understanding currently exists as to what format or level of intervention is most appropriate for various adolescent clients and diagnoses (Kumpfer et al., 2003; Liddle, 1996; Robin et al., 1995). Successful interventions in family-based treatment have been guided by family systems approaches and the understanding, assessment of, and practices supporting, healthy family functioning and the working alliance (Shelef et al., 2005; Wilcoxon, 1985). How WT programs embody these principles and practices is yet untested. It is important to recognize two parallel therapeutic processes that exist in WT: (a) adolescents participate in WT treatment primarily separate from their families, and (b) families are involved in WT programs in a number of ways including phone contact with therapists, letter writing, engagement of therapeutic and educational services in home communities, and times of inclusive family involvement during their child’s treatment. Studies of family involvement should take into account theoretical underpinnings, process variables and adolescent and family related outcomes. Types of family involvement and working alliances should be considered and the family—as a unit of measure—should be utilized rather than the adolescent client alone. Four conclusions are drawn from this review and illuminate the need for evaluation of family involvement in WT: (a) the number of WT programs are growing and developing as family needs for interventions increase, (b) family involvement is 45
clearly indicated as a best practice in adolescent treatment, (c) WT recognizes the need to involve families and many programs have adopted a family systems philosophy, (d) changes in the family system and strong therapeutic alliances may be indicative of overall success in adolescent treatment. Further, it is evident that WT programs and client families face significant barriers to involvement and programs will need to better understand how best to involve families effectively and efficiently. Regarding the current study, literature highlighted the need for an empirical approach to future WT research. While the “gold standard” random controlled trial seems unattainable, an alternative has been suggested to more completely illuminate family involvement in WT: an evaluation of theory, process, and outcomes which can build and test itself within the study. Level of intervention, format of family involvement, strength of parent-therapist alliance, and duration of programs should be considered variables in research on family involvement in WT. Using the WT program model utilized in OBH, this research will examine the whole family as the unit of measure rather than the adolescent alone.
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CHAPTER THREE: METHODOLOGY Introduction The purposes of this study were to (a) examine how families are involved in adolescent wilderness therapy (WT), (b) identify related outcomes and experiences of adolescents and families involved in WT, and (c) to further examine WT program and process theory focusing on families as the key unit of analysis. To accomplish this, a mixed-method approach utilizing a concurrent triangulation strategy guided two phases of the study: (a) a qualitative examination of the family involvement process, and (b) a quantitative evaluation of adolescent and family outcomes. The qualitative phase employed a case study design while the quantitative phase utilized a repeated-measures design (Creswell, 2003; Yin, 2003). A brief review of the epistemological debate between quantitative (e.g., positivist, post-positivist) and qualitative (e.g., constructivist) research paradigms provides support for the utilization of a mixed-methods research design in addressing the three primary aims of this study. Next, each phase of the study including specific research questions, hypotheses, methods and protocols employed are described. The chapter concludes with an overview of ethical considerations and the institutional approval process. Mixed-Methods as a Research Approach The two major research paradigms, quantitative and qualitative, have often been depicted in research methodology literature as being dichotomous and incompatible (Guba & Lincoln, 1994; Sale, Lohfeld, & Brazil, 2002), while other authors have supportively encouraged the use of both as advantageous in education, social science and 47
behavioral research (Greene, 2005; Hanson, Creswell, Clark, Petska, & Creswell, 2005; Onwuegbuzie & Leech, 2005). Johnson and Onwuegbuzie (2004) and others have described a philosophical stance in support of the mixed-method approach as pragmatism. The development and publication of theory and practice using mixed-method approaches are now more prevalent in literature (see Creswell & Plano Clark, 2006; Hanson et al., 2005; Tashakkori & Teddlie, 2003). Patton (2002) contends that the pragmatic approach “aims to supersede the one-sided paradigm allegiance by increasing the concrete and practical methodological options available to researchers and evaluators” (p. 71). Figure 1. Mixed-methods model with concurrent triangulation strategy and adolescent, parent and staff as unit of analysis
Child Parent
Phase 1: Qualitative Case study design *Interviews *Observations *Archival data
Phase 2: Quantitative Longitudinal repeated measures design *Family Function * Working Alliance *Youth Outcomes
Child
Parent
Staff Analysis
Analysis
*constant comparative *iterative *theory development
*descriptive *t-test *anova *correlations
Interpretations and integration of findings This “pragmatic” approach using mixed-methods guides the examination of the process and outcomes of family involvement in adolescent WT programs. This design, 48
emerging within social sciences, is a more comprehensive way to address a research problem from multiple perspectives (Johnson & Onwuegbuzie, 2004). Qualitative and quantitative methods will remain independent of each other in their concurrent utilization (see Figure 1) but will provide alternative understandings of the phenomena and reduce limitations of employing only one approach (Creswell, 2003). The integrated findings of these two approaches provide the researcher with the greatest opportunity for increased understanding of family involvement in adolescent WT programs (Johnson & Onwuegbuzie, 2004). Pragmatism is understood by the researcher as a central tenant guiding mixed-method research. The following passages will describe the rationale for the utilization of methods for each phase of the study. Phase I involved gathering and analyzing rich qualitative data within a case-study design, and included conjoint family interviews when feasible, parent and adolescent individual interviews, and observations of program practices, participants and staff (Miles & Huberman, 1994; Yin, 2003). Ultimately, this phase provided multiple descriptions of the process of family involvement in WT through the utilization of phenomenological techniques seeking the “lived experience” of families (Creswell, 2003). As a qualitative researcher, the approach assumed the constructivist notion that reality has multiple meanings that are grounded in the beliefs of the participants and that you as a researcher create the meaning through interaction (Denzin & Lincoln, 1994). Qualitative methodologies will be further described in the Phase I section below. Phase II assessed baseline and change due to treatment in levels of (a) family functioning, (b) adolescent treatment outcomes, and (c) the working alliance between client-therapist and family-therapist and the inter-relationships of these with program49
and participant-level variables. In this quantitative phase, the researcher accepted the positivist notion that reality is independent and can be objectively measured. Measures utilized to assess these outcomes are well recognized as valid and reliable instruments in literature of related fields (e.g., psychology, social work, family therapy) and have excellent psychometric properties that will be discussed. These measures will allow for both inference and comparisons to similar studies in related areas of adolescent and family mental health practice. Quantitative methodologies are further described in the Phase II section below. Phase I and Phase II will be given equal priority in this study, analyzed separately, then integrated (i.e., triangulation of methods) in the study’s discussion and conclusions (Chapter 5). Qualitative: Phase I The qualitative phase of the study engaged parents and adolescent in ways that allowed their stories to be told and provided an alternate view of the WT process including real-time perspectives, emotions, and insights of parents and adolescents in treatment for behavioral, emotional, psychological or substance use disorders. Although the family was the primary unit of analysis (Patton, 2002), program staff and administrators also participated in this phase to the extent that they furthered the goal of the research (i.e., to understand the experience and process of family involvement in WT programs) and are considered embedded units of analysis. Specific research questions that guided this phase are: RQ1- What theory guides family involvement in WT programs? RQ2- What processes are utilized in working with families in WT?
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RQ3- What meaning does the WT experience hold for families? RQ4- How did WT affect individual and family outcomes?
Participants Program Selection Two OBH programs who have families participating in treatment were selected for this study: (a) Catherine Freer Wilderness Therapy Expeditions (CWFT), a threeseven week WT program in Albany, OR, and (b) Aspen Achievement Academy (AAA), an eight week WT program in Loa, UT. Both programs are: (a) members of the Outdoor Behavioral Healthcare Industry Council and the Outdoor Behavioral Healthcare Research Cooperative, (b) accredited by the Joint Council on Accreditation of Healthcare Organizations and (c) licensed by their respective states as adolescent mental health treatment facilities. Participant Selection General inclusion criteria for this study were for adolescents and their families to be actively seeking treatment at one of the two selected WT programs in this study between June 1st and September 15th, 2006. Further exclusion criteria was applied by program administrators in the admission process and included adolescents with the following pre-treatment characteristics: (a) concern for suicidal or self-harming behavior, (b) history of violent or sociopathic behavior, (c) history of psychotic breakdown, (d) severe addictions, (e) medical or physical conditions preventing full participation, and (f) low likelihood of securing residence following treatment. 51
Families who were purposefully selected (Patton, 2002) based on the above admission dates were asked to participate in the study by the admissions coordinator (generally a licensed social worker, master’s level counselor, or clinical psychologist). These coordinators were provided with study protocols to inform and advise all incoming adolescents and parents of the study content and their right of refusal to participate in the research project. This process included a description of the benefits of the research for participants and potential risks and their maintenance (e.g., confidentiality). At any point during the study, if a participant wished to drop out, they reserved the right to do so. Admissions coordinators were also provided parent and child consent forms and a cover letter further describing the study for adolescent participants and family members upon their first contact with programs (See Appendices E-G). Approximately seven adolescent clients make up a WT cohort at each program. The goal was to select one cohort group from each program, which resulted in 14 families selected for participation in the qualitative phase of the study. While the intention was to conduct intact family interviews, the realities of program designs prevented this from happening consistently. One parent of each of the 14 families was contacted by phone at the three designated times (pre-treatment, post-treatment and two-months post-treatment). Ten of the 14 adolescents were met by the researcher in the field, of which, all were observed, spoken to informally, and three were interviewed formally through phone contact post-treatment. Twenty WT program staff, including therapists, field staff and administrators also consented for formal interviews in the study and were observed and in dialogue with the researcher informally throughout field visits at each program.
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Population Description Adolescent participants were drawn from WT programs where previous research has been conducted so demographics are reasoned to be similar to these samples as demonstrated by consistent repetition (see Russell, 2003b, 2006b). WT clients primarily enter treatment through adjudication by the court system or are directly referred by parents and are placed in a wilderness living environment to participate in educational and therapeutic activities (Russell & Hendee, 2000). Russell (2003b, 2006b) described WT participants as being between 16-18 years of age, 65% male, and over 65% being diagnosed or having an existing behavioral and emotional disorders (i.e., as defined by the DSM-IV (American Psychiatric Association, 1994) including issues of defiance, conduct, substance use and depression. Russell also noted that close to 75% of referred adolescents had already tried outpatient treatment for their problems. Russell and Phillips-Miller (2002) outlined five major contributing factors explaining why adolescents came to be in WT programs: (a) school problems, (b) drugs and alcohol misuse, (c) resistance to other forms of counseling, (d) suppressed anger and emotions, and (e) clients asking for help. If these factors represent the reality of most WT clients and families, then WT programs are reasoned to be providing service for adolescents and families in crisis and who may have experienced limited success with conventional mental health interventions. Treatment Protocol Adolescent participants in WT interventions generally experience similar treatment routines. CFWT is three to five weeks in length (depending on client success 53
in meeting treatment goals) and AAA is eight weeks in length. Parents will have contact with programs primarily through remote relationships with program staff (e.g., phone calls with therapists). Families are generally involved in admission or discharge activities and psycho-educational sessions (i.e., seminars, multi-family meetings) that may take place in separate, conjoint, or multi-family group format sessions. Specific treatment protocols recognized as consistent in OBH WT programs are (a) treatment occurs in a wilderness expedition model, (b) is guided by an individualized treatment plan, (c) therapy is directed by a licensed clinical team, (d) therapeutic practices are eclectic in nature, and (e) families must agree to participate for adolescent referral acceptance (Russell, 2001; Russell & Hendee, 2000; Harper, 2005). Data Collection Methods Researcher and Participant Observation Qualitative observation has been described by Adler and Adler (1994) as “drawing the observer into the phenomenological complexity of the world” (p. 378). The ideal epistemological position is to be an unobtrusive observer and researcher; this is best accomplished when the researcher can build a relationship with the group or individuals being observed. It is also of critical importance that the researcher conducts observation with discipline and rigor (Patton, 2002). Patton goes further in describing the need to be versed in program setting and context, reducing the need to rely on prior conceptualizations or be faced with uncertainty in interpreting observations. In this regard, the researcher should feel competent, knowledgeable, and comfortable in the research environment. The researcher’s work history includes over ten years of working 54
and communicating with similar clients and families, and practicing WT in treating adolescents in wilderness environments. He has worked in front-line service delivery, supervision, and management of adolescent wilderness treatment programs as well as completing external reviews/audits of related programs while maintaining objectivity and providing fair and honest reporting. Researcher-observation and participant-observation were both utilized in this phase. Researcher observation is described as an outsider looking in approach while participant-observation involves an insider looking around approach (Patton, 2002). Rather than believing that a researcher has full control over which approach will be adhered to during a qualitative study, this researcher assumed that a spectrum exists between the two and that finding a combination that will yield the richest results is most appropriate (Patton, 2002). When observing clients, families, staff and administrators, levels of involvement and the impact the researcher has on the setting needs to be considered. As the primary focus of the study was adolescent clients and their respective families, observation was conducted as a participant-observer when they were present to reduce the influence the researcher may have had on participants. Observation of program administration however, was different in that there was no intent to participate in the administration or running of each program, so a researcher-observer role was adopted. The researcher needed to shift approaches as necessary to avoid interference with program activities and the circumstantial needs of clients and their families. Further, the level of trust and respect of the participants was cultivated to encourage dialogue and gain rich content in order to achieve continued development of meaningful relationships. This process required a heightened sensitivity on the part of the researcher. Experience 55
working with this population reaffirms the importance of remaining sensitive to the needs of all participants and program staff, as ultimately, the researcher is an outsider to them all. Field visits totaling 22 days were undertaken at the two selected WT program locations and strategically chosen to best observe programming that included significant family involvement. This was primarily at adolescent admission and discharge (i.e., 2-3 days total family attendance). Observations also included the working relationships between field, clinical, and administrative staff and the clinical interactions between program staff, adolescent clients, and their families. The goal of the observations and informal interviews was to gather a collection of impressions that eventually lead to interpretation and analytical conclusions that eclipsed what could be recorded in field-notes taken during observations (Patton, 2002). Research aims guided data collection in the field examining (a) what theory programs utilized in involving families, (b) how programs involved families, (c) and what families experiences and saw as outcomes of their involvement. Field journals were utilized to record observations, impressions, and statements of participants and staff. Notes were detailed, concise, taken timely and included working hypotheses which developed throughout data collection and analyses. As memory tends not to serve the field researcher well, writing promptly and as frequently as possible served the researcher and this study immensely (Emerson, Fretz, & Shaw, 1995; Patton, 2002). The researcher approached this process with the level of discipline required for quality field notes as well as recognizing and adapting to the potential negative impacts
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an observer’s note-taking can have on a clinical adolescent population and their families under the stress of their situation. Participant Interviews Participating families were to be interviewed at or near (a) pre-treatment, (b) posttreatment, and (c) two-months post-treatment. As the realities of field work and interviewing logistics became more real, original plans to conduct complete family interviews was modified. Adolescents were informally interviewed upon admission and parents became the primary interview participants at each designated time. One parent was identified for each adolescent admitted to WT programs and interviewed by phone or in person at the three designated times. Ten of 14 adolescents of families chosen for the qualitative phase were eventually interviewed informally during their time in treatment; only a three situations arose where it was possible logistically to have conjoint family interviews (e.g., during a family solo at AAA). Formal parent interviews were semistructured and employed a general interview guide (see Appendix I) to provide continuity between parent interviews (Seidman, 1998) and the pre-treatment, post-treatment interviews were all completed as planned. Two families were difficult to track resulting in one two-month post-treatment interview not being completed and one not being digitally recorded, rather it was completed via email correspondence. Adolescent interviews were informal as the timing during their treatment and situations they were varied. While the interview guide was present during time spent with adolescents, it was only used to maintain conformity to the type of questions asked of parents. Three
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adolescents were formally interviewed post-treatment during the second interview with parents (i.e., they had returned home following treatment). Awareness was given to the emergent nature of semi-structured interviews recognizing the potential valuable data that may surface. Questions were open-ended, sequenced to build rapport, and encouraged openness to more personal content in later questions. Neutrality was maintained in conducting the interviews and the researcher only provided necessary feedback to encourage and move the interview toward the goal of collecting valuable personal experiences relative to the stated research aims and questions. Admission, discharge and follow-up interviews were 25 to 40 minutes in length allowing additional time to families desiring to share more, or for the need to bring closure to certain topics. This was especially critical for participants bringing up sensitive or complicated issues they felt needed to be heard to truly understand the family dynamics. Each interview concluded with an expression of gratitude for participating and was immediately followed with up to an hour of field notes to further reflect on, and capture interview content. Member-checking interview content was conducted through sharing of previous interview themes prior to starting the next interview. This procedure assisted in confirming accuracy in transcription and interpretation of what was said (Creswell, 2003). Member-checking procedures are further described below. Data Management and Analysis This qualitative study produced permanent records in the forms of audio recordings of interviews and researcher field notes. All observations, interviews and field notes were transcribed into text files and uploaded into NVivo qualitative data analysis 58
software, Version 2 (QSR, 2002). All data are protected for client confidentiality through double-locking procedures (see ethical considerations section). The researcher utilized an inductive approach to identify emerging patterns, and become acquainted with the data to interpret the findings (Gray, 2004; Miles & Huberman, 1994). This process involved a three-step process: (a) reducing data through identifying what data are similar (e.g., coding and categorizing), (b) seeking and describing patterns and relationships between codes and categories, (c) revisiting data to provide more intricate layers of understanding, linkages to elements described, and to source new or further understanding from the data (Patton, 2002), and concluded with the integration of researcher reflection and insight from field notes, adding further depth and insight to the findings (Gray, 2004). The process of integrating the findings of the qualitative and quantitative inquiries is described following the description of Phase II. Trustworthiness For any research to be deemed valuable it needs to provide the reader with evidence of rigor in design, systematic data collection and analysis, and a neutral approach to the phenomena under study (Patton, 2002). This study utilized (a) triangulation, (b) member-checking, (c) neutrality, and (d) transferability to increase the trustworthiness of its qualitative findings. Triangulation is the use of multiple sources of data, methods or researchers in analyzing a phenomenon (Patton, 2002). This study triangulated data from (a) transcribed family interviews, (b) informal interviews with program staff collected from either transcribed recording or researcher field notes, and (c) researcher observations of
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program processes collected as field notes. These three sources provide strength to support findings of the study through cross reference of thematic or conclusive outcomes. Member checking is a primary strategy to increase accuracy in qualitative findings (Creswell, 2003). Member-checking was employed in this study in two forms: (a) clarifying questions was asked during interviews and dialogue during observations to reduce researcher misinterpretation and more clearly articulate participant understanding of their WT experience, and (b) participants in family interviews were presented with the results of preliminary analysis and researcher interpretation from each prior interview and asked to provide feedback and further clarification on their contributions. Additional understanding came from responses and perceptions of study participants when they reviewed the researcher’s findings (Patton, 2002). Being present to these reactions, the researcher recorded new understanding, and tracked changes as indicated by participants in clarifying their contributions. This process was not utilized following the third and final interview. Effort to maintain neutrality is demonstrated through disclosure of researcher’s personal biases in interpretation of findings. Biases and limitations of this study are fully disclosed to ensure no misinterpretation or perceived deception is present. With an employment history in related programs, researcher knowledge and comfort level in this environment remained a constant source of potential bias. The awareness of this potential bias was maintained and acknowledged in field notes. Transferability has been posited in qualitative research as a parallel concept to generalizability in quantitative research; an application that attempts to make explicit how the interpretation of a study may be related to others (Patton, 2002). The qualitative 60
study design includes purposive sampling and the opportunity existed to make comparisons with, and assumptions about similar WT programs of OBH (Gray, 2004). Quantitative: Phase II A longitudinal repeated measures design (pre-treatment, post-treatment and two months post-treatment) was utilized to assess outcomes of approximately 200 adolescent clients and their families. Three psychometric instruments were employed to assess (a) family functioning, (b) individual adolescent outcomes, and (c) the working alliance. Each of these variables is further elaborated in more detail following an overview of research aims and hypotheses. Study design, participant selection, procedures, and limitations are described for this quantitative phase. Ethical considerations and internal review board procedures describe Phase I and II inclusively and will conclude with an overview of the triangulation process used to integrate qualitative and quantitative findings. Research Aims and Hypotheses: Phase II Specific Aim 1. To assess baseline and subsequent change in family functioning utilizing the Brief Family Assessment Measure (BFAM, Skinner, Steinhauer, & Santa-Barbara, 1983) over time. Ho1: Families of adolescents participating in OBH treatment programs will experience no difference in BFAM scores pre, post and two-months post WT program as assessed by three subscales (Ho1a General, Ho1b Dyadic, and Ho1c Self). Specific Aim 2. To assess baseline and subsequent change in adolescent social and behavioral outcomes utilizing the Youth Outcomes Questionnaire 30SR (YOQ, Burlingame et al., 2001) over time. Ho2: Adolescents participating in OBH treatment programs will experience no difference in YOQ 30SR scores pre, post and two-months post WT program. 61
Specific Aim 3. To assess baseline and subsequent change in client-therapist and familytherapist working alliance early- to post-treatment utilizing the Working Alliance Inventory (WAI, Horvath & Greenburg, 1989). Ho3: Families of adolescents participating in OBH treatment programs will experience no difference in WAI scores early- and post-WT program. Specific Aim 4. To examine potential explanations of change in dependent variables due to single or multiple participant and program variables. Ho4: Program and participant variables will have no statistical influence in outcomes for dependent variables (BFAM, YOQ, and WAI).
Constructs and Instrumentation Table three provides a brief overview of three latent variables assessed in the study: (a) family outcomes, (b) adolescent outcomes, and (c) working alliance. Each instrument is described including its content and psychometric properties. Table 3. Constructs and measures for quantitative analysis: Phase II Construct Family function
Variable Dependent
Measure Brief Family Assessment Measure (Appendix H)
Subscales Self Dyadic General
Adolescent outcomes
Dependent
Youth Outcomes Questionnaire (Appendix I)
Working alliance
Independent Working Alliance Goal Inventory Task (Appendix J) Bond
Reference Skinner et al., 1983
Burlingame et al., 2001
Horvath & Greenburg, 1989
Brief Family Assessment Measure The construct of family function is reasoned to consist of six key facets: task accomplishment, role performance, communication, affective expression, control, and 62
values and norms (Skinner et al., 2000). This construct was developed within the Process Model of Family Functioning which essentially emphasizes that healthy family dynamics are based on the accomplishment of key tasks by the family while the other five facets support this ultimate goal. Rather than identifying levels or types of dysfunction, importance is placed on basic interrelationships between members of the family and the family as a whole to provide an indictor of family functioning. This assessment approach is strongly aligned with family-therapy beliefs and family systems theory (see Becvar & Becvar, 1999). The Family Assessment Measure (FAM) is a pencil and paper instrument (see Appendix F) providing a systemic look at family functioning and may be used by family members 10 years of age and up (Horvath & Greenberg, 1989). The measure consists of three subscales: (a) General Scale focusing on family-as-a-whole, (b) Dyadic Relationship Scale measuring relationships between pairs of family members, and (c) Self-rating scale to identifying the individual’s perceptions of their level of functioning within the family (see Table 3). The FAM has been described in the literature as a reliable ( = .86 and .95 on all scales) and valid instrument with predictive and explanatory qualities (Skinner et al., 2000). Fourteen-item versions of the three components of FAM (i.e., General, Dyadic, and Self-rating) are available in a shorter instrument, the Brief Family Assessment Measure (BFAM). The BFAM produces an overall index of family functioning when time or resources limit the use of the FAM. Although lacking the clinical detail of the FAM, the BFAM is appropriate for identifying change in family function through repeated measures over treatment duration (Skinner et al., 2000). Each BFAM Scale 63
takes approximately five minutes to complete and is easily calculated using a scoring table included with the instrument. Youth Outcome Questionnaire The demonstration of effectiveness in adolescent mental health has become increasingly called for requiring rigorously developed and field practical measures of outcome. The documentation of treatment efficacy through adolescent specific measures has now become the domain of multi-disciplinary teams that include clinicians, academics, and managed care administrators (Dunn, Burlingame, Walbridge, Smith, & Crum, 2005). A well-proven instrument with the ability to detect change in social and psychological well-being of an adolescent was chosen for use in this study (see Russell, 2003b). The Youth Outcome Questionnaire 30SR (YOQ) is a 30-item self-report instrument (see Appendix H) measuring change in psychological symptoms and social functioning in adolescents (Dunn et al., 2005). This measure is a short version of the YOQ 30.1 which was developed to identify six content areas: (a) Interpersonal distress, (b) Somatic, (c) Interpersonal relations, (d) Critical items, (e) Social problems, and (f) Behavioral dysfunction. While assisting in ease of data collection, the YOQ 30SR does not allow for subscale analysis. It is however, ideal for repeated measures and shorter administration times in the WT setting as the instrument takes approximately 10 minutes to complete. Additionally, while clinician and parent reports can be made with this measure, only the adolescent self-report questionnaire was utilized in this study.
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The YOQ is considered a valid and reliable instrument ( = .74 to .93 on subscales with a total scale = .96) to assess adolescent outcomes and has shown effectiveness in repeated measure studies (Burlingame et al., 1995). The YOQ was first used to assess outcomes by OBH WT programs in 2000 and is still used as a tracking tool for programs participating in OBHRC. The use of the YOQ will allow comparison of this study’s results with previous OBH research findings (Russell, 2003b). Working Alliance Inventory Since psychology literature has recognized the general effectiveness of many treatment modalities (Weisz et al, 1995), effort has been directed toward identifying specific factors contributing to outcomes across multiple modalities (Horvath, 2001). One integral facet of treatment identified as positively contributing to the success of counseling and therapeutic practice is the quality and strength of the relationship between client and therapist (Horvath, 2001). Several studies of the “therapeutic alliance” have been explored in greater depth in Chapter Two; in short, the alliance has been demonstrated as the strongest in-treatment predictor of outcome (Bickman et al., 2004) and is based on agreements and cohesion between the individual in need of change and the designated change agent (e.g., client and therapist) (Horvath & Greenberg, 1989). The Working Alliance Inventory (WAI) is a 12-item self-report pencil and paper instrument (see Appendix G) providing a measure of the quality of alliance between therapist and client (Andrusyna, Tang, DeRubeis, & Luborsky, 2001). The measure of alliance consists of three subscales: (a) Goals (client and therapist agreement on treatment objectives), (b) Tasks (agreement on how to achieve stated objectives), and (c) Bond (the 65
quality of personal connection between therapist and client) (Horvath, 2001). The WAI has three available versions: (a) client self-rating, (b) observer rating, and (c) therapist rating. The client self-rating WAI was utilized in this study takes approximately 5 minutes to complete. The WAI instrument has adequate reliability ( = .89 for Goals scale, .92 for Task scale, and .93 for the Bond scale) and is highly related to other alliance measures (Cecero, Fenton, Framkforter, Nich, & Carroll, 2001). Three minor modifications were made to the WAI for this study: (a) removal of the word “therapist,” (b) Likert scale reduction from 7 to 5 possible responses, and (c) two reverse scored items were reframed in the positive. The word therapist was substituted to allow clients to choose any member of the clinical team to evaluate the alliance they perceived existing between them. This modification was facilitated as the wilderness treatment program utilizes a team approach to wilderness leadership and therapeutic intervention, reducing emphasis of the distinct roles and training each team member possesses. For example, the item “My therapist and I like each other” was rewritten as “_____ and I like each other” as seen in Table 1, allowing the client to choose a non-therapist team member to use for both pre- and post-measures. A maximum of 60 points were possible with the 12 items scored on a five-point Likert scale with responses as follows: 1- seldom, 2-sometimes, 3-fairly often, 4-very often, and 5always. A 5-point approach was adopted for the smaller sample size as it sought to encourage stronger responses than capable with a 7-point scale. The final modification was reframing the two negatively worded items used for reverse scoring. This decision was made for two reasons: (a) to maintain the strengths-based tone of the rest of the inventories items, and (b) to reduce potential errors in data collection and analysis. 66
Variables Independent Variables Independent variables to be included in analysis are (a) age, (b) gender, (c) diagnoses, (c) treatment length, (d) difference in working alliance score, and (e) program. Dependent Variables Dependent variables to be included in analysis are (a) BFAM scores of parent and adolescent perception of family functioning, (b) YOQ scores of adolescent behavioral and emotional outcomes, and (c) WAI scores of parent and adolescent therapeutic alliances with program therapists. Participants Program and Participant Selection The sample frame for this study was clients and family members of two selected OBH programs utilizing WT (see Phase I description for details). All adolescent clients admitted between June 1st and September 15th and one respective parent per client were asked to participate in this quantitative phase. One adult family member was asked to participate along with the adolescent in treatment to be included in this Phase of the study. Sample Size and Attrition The current study proposed a sample of 250 adolescents and an additional 250 parents. Data collection at each program site was found to be more difficult than anticipated resulting in a smaller sample than desired. This quantitative phase included 67
115 adolescent participants from two OBH programs and an additional 85 family members resulting in a sample size of N = 200. Attrition is described as the loss of research participants prior to completion of the study. With high completion rates in OBH programs (Russell, 2001), admission and discharge measures were expected to be 93-97%. The two-month follow up measure was expected to experience a 25-30% attrition rate as participants and their families are often engaged in aftercare with different service providers, move, or just do not maintain contact with WT programs, or simply don’t complete assessments when contact is established. Participating program staff administering the measures attempted to limit attrition through close client contact and extended contact with families post-discharge. Attrition occurring between pre-treatment and post-treatment was 28% and the twomonth follow-up period saw excessive attrition, nearing 98%. This occurrence was unexpected and prevented any follow-up analysis on quantitative measures thereby reducing the potential of this phase of the study. Procedures Longitudinal Repeated-Measure Design Table 4 depicts the quantitative measures and the timeframes in which they were intended to be collected. The BFAM was administered three times to identify change in family function. A baseline measure was taken from all participating adolescents and parents upon admission (pre-treatment), at discharge (post-treatment) from the program, and again at two months post-treatment. The YOQ was administered at admission for a baseline, at discharge to assess change during program, and again at two months post68
treatment to assess maintenance of change or further gains. The WAI was first measured early in the program: within seven days of admission as (a) current literature has shown early alliance as a strong predictor of outcome, and (b) adolescents and parents are unable to immediately report on quality of therapist relationship at admission. Late administration of the first WAI measure presented possible ceiling effects as clients and therapists alliances build relationships at different rates. As the relationship of interest is reasoned to be weak upon admission, program staff were asked to administer the measure when they believed the client’s resistance to treatment or anger upon their involuntary admission, subsided. The WAI instrument was used again at post-treatment to assess the level of therapeutic relationship developed between the adolescent client and therapist, and parent and therapist. Table 4. Repeated measures timeline of Phase II quantitative study Participant
Pre-treatment
Parent
BFAM
Adolescents
Early
Post-treatment
Two-months post-treatment BFAM
WAI
BFAM WAI BFAM WAI YOQ
BFAM
BFAM WAI YOQ
Admission dates beginning: June 1st, 2006 Discharge dates up until: Nov. 15th, 2006 Follow up: Two months post-discharge
BFAM= Brief Family Assessment Measure WAI= Working Alliance Measure YOQ= Youth Outcome Questionnaire *WAI was administered within first week of admission date.
Many adolescents participating in the study were originally resistant to treatment and had been coerced or escorted to the program by an escort service or legal authorities. For this reason and others, measures were administered at appropriate times for clients 69
and their families as determined by the clinical team to prevent the research from interfering with the treatment process. Data Collection Adolescents and the primary parent completed measures at designated times and within the logistics established by the researcher and designated contacts at each program. The three identified measures for this study were pilot-tested in spring 2006 for sample analysis in preparation for the study. The two WT programs collected quantitative data during their regular contact with study participants pre-treatment and post-treatment, but were unsuccessful at two-month post-treatment in collecting the follow-up measures. Quantitative data was de-identified by programs by the removal of client names replaced by client identification numbers. Program and client codes were then collated in the data base. Data collected on all three measures were entered and managed using the Statistical Package for the Social Sciences (SPSS, version 14 for Windows, 2004). Data Analysis The primary aims of data analysis in this phase were to (a) identify differences in family functioning, adolescent well-being, and working alliances over time, and (b) to understand interrelationships between client and family outcomes, and between these outcomes and participant- and program-level variables in the WT process. Data were entered, cleaned, and checked for non-response and participant- and program-level biases. Frequencies and distributions were checked to ensure individual values were within expected ranges, that means and standard deviations were plausible. 70
Assumptions of normality were confirmed and the data was checked for outliers and treated if deemed necessary. Data was then analyzed for descriptive statistics to provide an understanding of sample characteristics and independent variable scores to be used in further analysis (Howell, 2002). Paired sample t-tests were the primary mode of analysis for change on the three repeated measures (BFAM, YOQ, and WAI). This pre-treatment to post-treatment analysis was due to the loss of the third follow-up data. Dichotomous variables (gender, program) were compared with t-tests, while treatment outcomes within subject factors of age, diagnosis group, and treatment length group were assessed using repeated measures ANOVA. Relationships between treatment outcomes were calculated using correlation and multiple regression analyses. These analytic techniques sought to understand change in adolescent and family outcomes and to provide an account of how change manifests in WT and to provide possible explanations of change across program and participant-level variables. Further, a number of analytic techniques increased the opportunity for complementary and contradictory interpretation of the qualitative findings. The BFAM, TOQ and WAI were tested for statistical (p = .05) and clinical significance (effect sizes suggested by Cohen, 1988). Further, the YOQ was assessed using guidelines developed by the authors of the YOQ for the Reasonable Change Index (RCI, improvement of ten points). The BFAM was also assessed according to predetermined standardized norms and percentiles set out by the scale’s authors. With multiple repeated measures paired t-tests being run and compared, alphas for tests of significance were reported at p < .05 and to demonstrate efforts to control for Family-
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wise Type I errors in reporting, significance at p < .01 is additionally tabled in the results (Howell, 2002). Mixed-Methods Triangulation Converging Inquiries Recent mixed-methods research using qualitative and quantitative approaches in Counseling Psychology have reported any findings of each approach separately, and have not often attempted to integrate these findings in a comprehensive manner (Hanson et al., 2005). Creswell (2003) described the difficulty in studying phenomena with a concurrent triangulation strategy (equally weighted and timed qualitative and quantitative approaches) and suggested the use of inductive exploration in addressing research aims. The researcher adopted this approach to integrate the findings of the two Phases of this study (see Chapter 5). Procedures Distinct procedures have been described for the design, implementation, and analysis of qualitative and quantitative approaches employed in this study. Findings from separate data analysis of each phase of inquiry are presented in Chapter Four. Each section is concludes with a brief summary followed by Chapter Five which concludes the dissertation through integration of qualitative-quantitative findings in the discussion and conclusions.
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Limitations Several limitations exist in this research design including non-utilization of a control or comparison group, randomized sampling, or random assignment. These limitations are due to ethical and logistical constraints. Participating programs in this study operate on client need and private-pay basis in which waitlists and excess demand do not exist (Russell, 2003a). It has also been argued in social sciences as to whether it is ethical to delay services for those in need for the sake of control group development in research (Patton, 2002). While findings are reasoned to generalize to similar WT programs, these generalizations are made cautiously. Further, due to small samples in program and participant-level analysis, and the lack of the third follow-up measure, quantitative analysis (outside of larger sample total score results) lacks statistical strength and is considered exploratory and informative of the study but does not infer its results across WT programs. Ethical Considerations Risks Overall, risks to participants for participating in WT treatment programs of OBH have been found to be comparable to normal adolescence risk levels in day-to-day activities (Russell & Harper, 2006). Ultimately, however, fatalities have occurred and due to the isolated nature of programs and often unpredictable behavior of adolescents in crisis, risk of injury, illness, and death are present. Risks from completing the questionnaires and participating in the study were believed to be minimal. Potential risks included (a) possible breach of confidentiality, 73
and (b) possible psychological agitation related to content of measures utilized in the study. Confidentiality was maintained through secure handling and limited access to personal data by the investigator. Psychological agitation associated with the quantitative measures was addressed through the administration of the instruments by the adolescent’s therapist or counselor. Similar psychological agitation may have occurred during the interviews with the researcher. Benefits As adolescent participants were already in a treatment program, they were addressing issues related to their family. The three psychometric instruments utilized in this study are primarily strengths-based (i.e., rather than focused on dysfunction or use of deficit terminology) and stimulated reflection and hopefully initiated dialogue between the adolescent clients, family members involved in the study, and the program therapists and field staff. These instruments also provided the therapeutic team with additional clinical assessment and insight into family relations from multiple perspectives. Moreover, results of this study may contribute to programmatic changes in the way WT programs involve families in the treatment process. As limited literature exist in this regard, parents and families of future OBH program participants may benefit from more effective service delivery and outcomes. Ethical Procedures Confidentiality of personal information was given the highest priority in this study. The participation of families and adolescents with mental health issues in research carries with it great personal responsibility for a researcher. All efforts to protect 74
participants from unnecessary harm were taken (e.g., setting boundaries on data collection and implementing safeguards to protect health information of participants). All potential participants were informed of the research study and given the opportunity to participate or not. All participants had the right to revoke previously signed authorization of use of their information. For example, at any time during the study a participant could request to remove their contribution. Participants also had the right to request an accounting of disclosures in certain circumstances. An example may be a request of a research participant to view the field notes taken by the researcher. Information about that individual will be made available if requested. The right of a participant to file a complaint against the researcher was made available through written material provided including numbers for the privacy officer and the Internal Review Board (IRB) office at the University of Minnesota. Efforts to minimize the use of names or identifying information were undertaken. Mental health information of participants in this study is protected from distribution through de-identification when possible and containment of material with locking mechanisms. The WT treatment approach delivered by field staff and therapists is licensed by state agencies and accredited by the Council on Accreditation (COA), the Joint Council on the Accreditation of Healthcare Organizations (JCHAO), and other accrediting agencies. Field staff and therapists were available to participants when support or assistance was needed regarding participation in the study. Although not intending to ask provocative questions during interviews, psychological distress may have occurred and the researcher assured participants that the clinical team was available in such 75
circumstances. In consideration of potential instability of adolescent clients and their respective family member’s mental health status, the researcher remained aware of the impact the study may be having on them. Participants were reminded of their right to discontinue involvement in the study if, in the researcher’s opinion, the need arose. Disclosure by participants of child abuse or intended self-harm was to be reported to program administration by the researcher. Internal Review Board Approval from the Internal Review Board for research with human subjects was granted by the University of Minnesota on July 16, 2006 (see Appendix B).
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CHAPTER FOUR: FINDINGS Qualitative phase Findings emerged from analysis of (a) more than seventy interviews with parents, adolescents and WT program staff, (b) twenty-two field days of program and participant observation, and (c) review of archival data including printed and electronic material for program training, management and marketing. Brief program descriptions and family involvement practices of Catherine Free Wilderness Therapy Expeditions (CFWT) and Aspen achievement Academy (AAA) will provide the reader with a contextual understanding of programmatic differences. Findings are then presented according to qualitative study research questions: (a) What theory guides family involvement in WT programs? (b) What processes are utilized in working with families in WT? (c) What meaning does the WT experience hold for families? and (d) How did WT affect individual and family outcomes? A vignette of one participating family from each of the two WT programs will follow to further illustrate findings, key emergent themes and client and programmatic differences. Family involvement: Programmatic differences Catherine Freer Wilderness Therapy Expeditions While located in Albany Oregon, most programming at CFWT occurs in forests and deserts of the Pacific Northwest and Nevada. CFWT is described in promotional and educational material as a program combining behavioral therapy, twelve-step approaches and individual and group psychotherapies within inherently healing wilderness environments. Further, CFWT utilizes psycho-educational and consulting practices in its 77
integration of conventional treatment approaches with families, demonstrating the diversity of this multi-dimensional approach. Designed for adolescents with a range of problem behaviors, CFWT provides participants with opportunities to raise awareness of their personal and family strengths and weaknesses, and ideally, leave with the skills to make better decisions in their lives (CFWT Parent Guide, no date). Theoretically, CFWT operates from a family systems and structural family therapy perspective in efforts to address dynamic family issues and to re-establish normal family process. Additionally, CFWT multi-family meetings were designed on the “multiple impact therapy” model which serves (a) as an intensive family assessment upon intake, (b) a facilitated transition meeting between trek and extended expedition or returning home, and (c) structured closure to a family’s time with CFWT. The foundation of most CFWT experiences is the 21-day trek. Program staff and material describe the trek as a “clinically sophisticated” and “highly choreographed” intervention including intensive individual and group process work integrating a number of therapeutic and psycho-educational approaches into this relatively short time-frame. Therapists live and travel with adolescents during the 21-day treks providing an intensive therapist-client relationship. A “supervising” therapist works with the family and field therapist in a “consulting” role providing direction and support to field staff and families remotely. Depicted by staff as an exceptional therapeutically conducive milieu, CFWT recognizes and utilizes the wilderness environment in a meaningful and significant way. Adolescents complete reflective journal assignments, solos and often hike and camp in silence further facilitating an individual treatment regime within a group experience.
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Following the 21-day trek, adolescents may continue on with CFWT in (a) a 30day extended expedition, (b) Santiam Crossing Residential Therapeutic Outdoor School, (c) Oregon Transition Homes, (d) other aftercare facilities or services, or (e) return to their family home. Participants in this study were considered attending CFWT until discharged from any of the CFWT programs mentioned except other facilities or services since CFWT programs include adventure and wilderness practices. This produced a range of treatment lengths ranging from 21 to 50+ days and averaging 38.3 days. Twenty-one-day treks begin and end with all-day multi-family meetings for each cohort of adolescents in treatment. The pre-trek meeting provides an overview of expectations for the child and parent’s participation, an assessment of family dynamics and adolescent problem behavior, and an opportunity for parents to meet other families in similar crises or circumstance. Family involvement in this meeting and other programming elements is required for their child’s enrollment at CFWT. Family involvement includes (a) attendance at the pre-trek and post-trek meetings, (b) enrollment in the Family IQ (an internet-based psycho-educational program, 2007), (c) identified and continued personal, marital or family counseling as needed, (d) research and contact potential aftercare programs and services, and (e) work with supervising CFWT therapist to read material and complete tasks as recommended (e.g., letter writing, searching room of child with substance abuse issues, talking with child’s friends or their parents about child’s aftercare plan, home contracts, etc). Weekly emails and telephone conversations between supervising therapists and parents allow for the flow of information between program, parent and child. Table 5 shows the similarities and differences between CFWT and AAA family involvement practices. 79
Table 5. Characteristics of family involvement at participating wilderness therapy programs Catherine Freer Wilderness Therapy Expeditions
Aspen Achievement Academy
Three week trek and possible four week Six to nine weeks in continuous extended expedition expedition *Family attends day-long admission *Family not in attendance at admission meeting Family expectations Family expectations home therapist home therapist Family IQ Family IQ Tasks and communication with Tasks and communication with program therapist program therapist *Family attends day-long meeting post- *Family attends 3.5 days post-program trek post-extended expedition in including 2 nights in wilderness outdoor setting Program therapist for child, consultant Program therapist for child, consultant and support for family primarily via and support for family primarily via phone and email phone and email Age appropriate siblings and extended Age appropriate siblings and extended family encouraged to participate family encouraged to participate Note: *differences in program practice related to family involvement Aspen Achievement Academy Located in the quiet community of Loa, programming takes place in the wilderness of South-central Utah’s high deserts, aspen groves and mountains. AAA is promoted as a sophisticated model integrating educational curriculum with insight therapy, symbolic rites of passage, and utilizing experiential teaching methodologies in a healing wilderness environment. Program interventions focus on the development of personal awareness of emotional and behavioral habits while establishing a foundation for self-reliance and the movement toward responsible adulthood (AAA Promotional Flyer, no date). Therapists at AAA describe family systems theory as guiding practice within a range of family oriented practice among their therapists; counseling, social work 80
and marriage and family therapy. Program staff described ongoing discussions and inhouse training on the concepts of a family systems and ways to increase program impact on the family. Individual behavioral and emotional responses are identified and discussed during the program to assist adolescents in recognizing and working toward changing these ineffective patterns. Individual counseling and group process sessions, reflective assignments, positive peer culture and intensive staff-adolescent relationships are identified as key therapeutic practices of AAA. Parents (a) take part in weekly treatment planning sessions with their child’s therapist by phone, (b) write letters, (c) complete written assignments and parenting materials on line, in book or audio formats, and (d) attend a multi-day family reunion prior to their child’s discharge. A major component of family involvement at AAA is the multi-family, multi-day workshop which concludes their child’s wilderness treatment. Parents travel to AAA for the three and a half day family reunion. Parents are first involved in a parent-only evening workshop designed to let everyone get to know each other and discuss expectations and details of the following days. This parent meeting allows for joining and normalizing of parent experiences and supports parent-to-parent feedback and sharing of ideas. A workshop the following morning focuses on parenting skills and begins the process of getting parents to experience breaking out of their comfort zones through experiential and psycho-educational activities focused on individual and family processes. These activities are framed in a similar manner to what their children have been through and further increase the openness and understanding of what their child may have experienced and learned in treatment. 81
The afternoon of the second day starts with the reunion of families with their child in treatment. A traditional “run in” takes place where parents and children run along designated trails toward each other; eventually meeting on symbolic “middle ground,” often in emotional embraces. The last two days include clinical group sessions, individual family counseling, and group discussions on a variety of topics (e.g., addictions, aftercare planning and home behavioral contracts, etc). Additionally, the parents spend two evenings on “family solos” and are provided for by their children, thereby experiencing similar conditions their children have lived with for the previous six to nine weeks. The family reunion concludes with a graduation ceremony and a return to AAA offices in Loa to meet with other program staff which adolescents may have worked with in the wilderness, and to make final preparations for transitions home or other aftercare residential settings. Qualitative Results Table 6 provides an overview of qualitative results including the alignment of 36 descriptive codes emerging from data and 12 subsequent pattern codes with the aims of the four stated research questions. Results will be described for each research aim by table, and further illustrated with supportive passages from interview transcriptions and researcher observation reasoned to be examples of each code. For example, the research aim addressing “process” will be explored first by the pattern code Family Issue and will include examples from each of its descriptive codes: (a) Family involvement, (b) Not alone, System awareness, and (c) Homework. Subsequent pattern codes Integrated Approach and Wilderness Setting and their related descriptive codes will follow.
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While two case study sites were established with CFWT and AAA, qualitative results are presented together in aggregate form. Participant experiences between WT programs are not assumed to be the same although data analyzed did not often present trends suggesting significant differences in programmatic, or overall family experience of WT. Differences do exist in program and staff practices, family composition, type and intensity of family involvement (previously depicted in Table 5) and relative to time during and following the WT treatment period. Differences will be reported when contributing meaningfully to the findings and understanding of each research aim. Further, these findings were drawn from adolescent, parent and family interviews, field observations and review of program documents which provided diverse and extensive material for this analysis. Table 6. Research aims, pattern codes and descriptive codes of family involvement in wilderness therapy Research aim
Pattern code
Descriptive code
Theory
Integrated Approach
Multi-modal Systemic and separate Whole person concept Physicality/ challenge Reflection Milieu therapy Trust in program Physical and emotional safety
Wilderness Setting
Safe Place
Process
Family Crisis
Meaningful Separation
Family Issue
Extreme circumstance Ask for help Fear of the worst Drawing the line Significant change Physical and emotional distance Family involvement 83
Not alone System awareness Homework Meaning
Mixed Emotions
Touchstone Experience
Abrupt Transitions
Outcome
Sense of Self
New Beginnings
Not Fixed
Hope and fear Guilt and shame Anticipation and happiness Connectedness Demonstrate potential Place of strength Involuntary participation Re-entry challenges Skill testing Calm and focused Assertive communication Pride Clean slate Inspiration Reorganizing family roles Stabilization False environments Systems of support
Theory: What theory guides family involvement in WT programs? Process: What processes are utilized in working with families in WT? Meaning: What meaning does the WT experience hold for families? Outcome: How did WT affect individual and family outcomes?
Theory Integrated educational and therapeutic approaches and environments utilized by AAA and CFWT programs with children, parents and intact families form the foundation of theoretical understandings of family involvement in WT. These approaches are grounded in systems theory that incorporates client and family needs with appropriate individual and family treatment planning and intervention. Therapeutic practices are then delivered within the group process of group wilderness travel and living and remotely with parents at home. Pattern codes describing theory underlying Family Involvement in 84
WT include (a) Integrated Approach, (b) Wilderness Setting and (c) Safe Place and are presented in Tables 7, 8 and 9, then further articulated with associated descriptive codes, definitions and examples.
Integrated Treatment Model A multi-dimensional service delivery approach is utilized by WT programs in addressing individual and family issues comprising clinical assessment and treatment planning, psycho-educational curriculum, individual and group counseling processes, and a wide range of program features for personal growth and development (e.g., wilderness skills, ritual, rite of passage and solo). Multiple educational and therapeutic practices acknowledge the diversity and complexity of participating client and family issues and provide a sophisticated and consciously evolving family treatment model. Descriptive codes comprising Integrated Approach include (a) Multi-modal, (b) Separate and systemic, and (c) Whole person concept are presented in Table 7.
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Table 7: Pattern code Theory: Integrated Approach with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Multi-modal
Programs operate from multiple perspectives and systems
"you've got therapists who are coming at it [therapy with clients] from different approaches, then they approach how to deal with families in different ways" (field staff-22-06)
Separate and systemic
Intersection between adolescent therapy and consulting family work at home
"While indirect, the information gleaned from the work with families and the work in the field have significant impacts on each other" (therapist, 16-06)
Whole person concept
Physical, emotional and cognitive experiences assumed integral to WT process
"the physical challenges were great, the mental challenges equaled that…it was, a pretty special way to delve into your psyche" (mother, 06-06)
With a relatively short intervention (i.e., 3-9 week), WT programs adopt a diverse and direct approach with both adolescent clients in the field and their parents at home. Multiple theoretical approaches to treatment were apparent with “structural family,” “humanistic,” “12-step” and “family systems” commonly cited by program staff and administrators. Programs therapists come from a diverse range of training and educational disciplines such as Counseling, Marriage and Family Therapy, Social Work and Psychology. Clinical teams are comprised of all staff working with clients and their families including wilderness leaders, field therapists, clinical directors and program 86
administrators, each bringing to the WT approach the strengths, beliefs and practices aligned with their respective fields. It is within this dynamic collection of professions that each programs Director and Clinical Director guide the service delivery model. A “consulting” approach was described by program therapists in their work with families and home therapists (i.e., pre-existing or established relationship with parents during WT to support the family during and post-treatment). This approach was depicted by one therapist as advantageous in that “you can be fairly forceful in what you present because you don’t have a lot of time…so your family understands the landscape they are dealing with” (therapist-17-06). A variety of program aspects cross boundaries and integrate practices from educational, psycho-educational, counseling and therapeutic fields. One program therapist stated that theoretical treatment approaches such as “Family systems, CBT, Narrative, Gestalt, and Existential Psychotherapy are all very well suited to family involvement in WT” (therapist-16-06). That said, program literature reviewed, and staff practices observed, demonstrated a high degree of understanding of meaningful applications and recognized best-practice of approaches utilized in serving clients and their families. Additionally, therapists and staff refer to other program features like the “wilderness environment” and “relationships” as equally important in the change process as any particular theoretical approach utilized. This was clearly summed up by a therapist who called WT “more of a milieu than a theory, it allows for varied approaches” (therapist-16-06). Dynamic and flexible theoretical approaches utilized by programs are supported by the simplicity of daily programming in the wilderness, the extended and intensive time spent with clients in the field, and the wide range of staff
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skills and resources available. Further discussion of this integrated approach is found in the discussion section of Chapter 5. WT approaches families through systemic and separate interventions which rely heavily on the quality of the relationship developed between client-therapist and parenttherapist. Therapists attempt to get the family “moving in the right direction” which often first necessitates individual child and parent work. One therapist related “the parents…and the kids need to go off, to have some separation and reflect on how it got to that point and how it’s going to get back to where it needs to be” (therapist-23-06). It is during that manufactured space that program therapists coordinate therapeutic processes in the field with clients and in home communities with parents and home therapists. While a primary aim of work in the field with adolescents is to work on how they communicate and act within their family system, program therapists “coach,” “inform” and “encourage” parents to address issues with therapists, family and other community resources available to them in their home communities. It is this belief, supported by family systems theory that change experienced in the WT program can better manifest in the families home and community post-program when those systems of support available to the family are engaged. In this regard, the integrated approach was seen as extending beyond program activities and family participation into the community as an integral part of the continuum of care for each family, even though most client family contact ends at discharge. While WT is a behavioral, emotional or substance use intervention, a “whole person” approach was generally observed in program practices. This approach emphasizes healthy meal planning, school curriculum being completed, the use of ritual 88
and discussions of spirituality, offering clients more than just a clinical psychotherapy process. Further to this holistic approach, theoretical consideration is given to the role of nature in the WT. While most obvious to field staff and adolescent clients living in the wilderness on a daily basis, this ecological approach was not a consistent finding. Nature was alluded to by a few program therapists as playing a credible role, suggesting it contributes meaningfully to the therapeutic process. One program therapist offered an eco-psychological explanation for WT, supported by other program staff in their descriptions of similar ecological, cultural and spiritual program practices such as the use of mythology, earth- or indigenous-based rituals and rites of passage activities. He stated: We are recreating the way that is in our bones to live and that’s living in the woods, living simply, in small groups of people who are interdependent and there is something inherently healing about that (therapist-20-06).
Wilderness Setting Program locations and the concept of “wilderness” serve to distinguish WT from other residential adolescent mental health and substance abuse treatment interventions. Conceptually, logistically and physically, wilderness is recognized by families as playing a significant part in their decision to send their child, and informed subsequent experiences related to their child’s WT treatment. Descriptive codes comprising the Wilderness Setting pattern code include (a) Physicality, (b) Reflection, and (c) Milieu therapy are presented in Table 8.
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Table 8. Pattern code Theory: Wilderness Setting with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Physicality
Recognition of the physical demands of wilderness living and travel as important in therapeutic process
"I think having been SO physically challenged …gave him the emotional space he needed to really look at things" (mother-1406)
Reflection
Ample opportunities for introspection on life and family situation
"I discovered allot about my role in the family…and how the roles had just shifted recently with all my problems" (female adolescent-05-06)
Milieu therapy
Increased likelihood of adolescent engagement and adherence to therapeutic processes in wilderness
"I don't think he would have gotten the same level of progress had he gone to a hospital-type program" (father-11-06)
Program staff, clients and parents recognize and acknowledge the strenuous physical nature of the WT intervention, although a clear or consistent rationale for its benefit was not articulated. As one client shared the difficulties experienced, she countered with her perception of positive gains stating “everyday was a struggle for me and it, it, I mean it made me face my, like anxiety, it made me, it was hard but, I got, I got a lot out of it” (female adolescent-06-06). When asked why they believed their children were successful in WT, the physical aspect was often expressed by parents although for a variety of different reasons. The following responses illustrating this diversity include an example of the humbling experience of living and traveling outdoors, the benefits of
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physical fitness for mental health and overcoming the challenges of discomfort and adversity.
“When you are outside and you’re doing things…having to function on your own…you start to realize that you’re just a smaller part of something large.” (father-12-06)
“We thought if he got physically fit maybe he would say ‘wow, I feel great’ and might launch him into staying fit” (mother-14-06).
“It puts them in a vulnerable position…it makes them feel uncomfortable and I think that they can become more comfortable with who they are…and able to express themselves and also find out, hey, I can survive, I can make it” (single mother-05-06).
Another commonly expressed yet not clearly agreed upon aspect of WT theory is the role of reflection in the therapeutic process. Both for families in their home environments and their children in WT, reflection was found to be a meaningful and valued experience. One parent described the role that “being in nature” had held for her son and she reasoned it to be an ideal environment for his treatment stating “when he’s out there hiking or walking or sitting next to a stream…he’s so much more relaxed…I am hoping he will be more open at that point in time and willing to work on his stuff” (father-12-06). Parents and staff expressed the removal from negative influences in the home community, coupled with a natural environment, as a place where adolescents may achieve “inner peace,” “calm” and “quietness of mind.”
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WT was observed and described as a milieu therapy rather than a theoretical approach to adolescent treatment. Program administrators, therapists and field staff articulated numerous therapeutic approaches utilized in WT. Program philosophy, client social and psychological need, therapist training and other variables determine the nature of interventions and practices undertaken by program staff. This descriptive code will receive further treatment in Chapter 5: Discussion and Conclusions. Inconclusive understandings of program facets such as the role of nature, the physical demands of WT, and role of significant individual reflection require further inquiry to better capture the contributions of these important variables within the milieu. One therapist captured a sense of the “mystery” of the WT milieu in the following passage: At first, the wilderness can provoke anxiety; however I consistently see families taken aback by the openness, vulnerability, and wisdom their children gain from being in wilderness. They quickly recognize that something happened out there [italics added]. They also get a taste of it…by spending time outdoors…noticing shadows, sounds, smells, etc., they get a sense of the context in which their child’s treatment occurred (therapist-16-06).
One consistent response from parents during and following WT supporting it as a potent milieu for therapy is the level of adolescent engagement and adherence to therapy that is experienced, especially in contrast to previous failed interventions. When asked what brought them to WT (see Interview Guide, Appendix K) parents related the lack of success of earlier therapeutic interventions, and recognized that something in WT increased their child’s “problem recognition” and as one parent stated WT “made a
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difference where the inpatient program didn’t seem to be able to make that much progress” (father of adopted son-11-06). Study participants recognized, but found it difficult to articulate, that there was “something else going on” in WT beyond conventional therapy.
Safe Place WT program staff, locations and practices were articulated by parents as characteristic of an environment they felt comfortable sending their children to for help. While “safe place” may seem somewhat paradoxical relative to modern conceptions of “wilderness” as a place of fear and uncertainty (Koole & Van den Berg, 2005) this finding needs to be considered relative to the extreme crises experienced by parents prior to admitting their child to WT. In this regard, the WT environment is considered in comparison with high-risk activities and environments their children were exposing themselves and the family to. Descriptive codes comprising the Safe Place pattern code include (a) Trust in program, and (b) Physical and emotional safety are presented in Table 9.
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Table 9. Pattern code Theory: Safe Place with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Trust in program
Parent confidence in program’s ability to keep their children safe
“we found it meaningful, understanding the environment and people he was entering it with, both counselors and the other patients” (divorced father-13-06)
Physical and emotional safety
Parents see program as nurturing and conducive to healing process
“I was relieved cause I knew he was safe, I knew where he was at, and I knew he was getting help” (single mother of adopted son-09-06)
Child removed from negative environments, harmful behaviors and substances; prevented from leaving
“the only place that could possibly contain him long enough where some type of therapy could get through to him” (father-10-06)
From the first phone call to their own participation in program activities, parents generally expressed considerable satisfaction and trust regarding their involvement with WT programs. The level of trust earned by WT programs was evident in parent responses throughout the study. The following passages from parents demonstrate the varied reasons for this level of parental trust in program:
I would stand in his room [concerned], but I never, you know, I never worried about his safety, you know I knew he was in a safe place, physically, as well as emotionally, and I knew it was the right thing to do (mother-02-06).
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I felt very supported by the people at [WT program] when I called, they were very helpful giving me the information I needed (divorced mother-adopted son-09-06).
While reflective of previously expressed parental trust of program, two distinct aspects of safety were described by families and WT program staff: (a) physical safety, and (b) emotional safety. Parent’s expressed their confidence in the program’s ability to manage behaviors that some parents admitted they couldn’t, and that their children could not run away from WT. Another aspect of physical safety found comforting to parents was the inability of their children to participate in inappropriate, risky and self-harming activities. One parent stated the obvious. “I did have comfort in that he was safe…that he wouldn’t get involved in illegal activities, you know that was my fear, that he would get arrested again” (divorced father-13-06). Emotional safety was achieved for parents and adolescents entering the WT intervention and a goal of program staff. As social and emotional bonds were being formed in parent and adolescents groups, participant comfort and increased ability to communicate openly was observed. One parent articulated the shift his son made toward addressing his addiction issues in saying “I don’t think [our son] was positive about it…I think things changed when he saw other people interact, you know, both parents and other students” (father-adopted son-11-06). Additionally, a number of parents described remarkable emotional risks taken by their children during WT, demonstrating to them an environment with a high degree of emotional safety. One parent stated in a posttreatment interview:
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He’s been in therapy, talking with different therapists he says he’s trusted for years, he goes to eight weeks of, you know, wilderness, and makes huge, huge leaps of progress, and insights into himself, and why things have happened, and um, taking responsibility, I just don’t think he could have done that, you know, even in a hospital setting. (single mother-01-06)
Process Family engagement in WT and specific program practices utilized with adolescent clients and their families is recognized as central to the therapeutic process. Patterns describing family involvement processes include (a) Family crisis, (b) Meaningful separation, and (c) Family issue are presented in Tables 10, 11 and 12 and are further articulated with associated descriptive codes, definitions and examples.
Family Crisis Family situations prior to admission of their child to WT were generally unstable and volatile, with adolescents at considerable risk and in need of a significant intervention to break a destructive pattern of harmful behavior. Descriptive patterns comprising the Family Crisis pattern code include (a) Extreme circumstance, (b) Ask for help, and (c) Fear of the worst are presented in Table 10.
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Table 10. Pattern code Process: Family Crisis with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Extreme circumstances
Serious stress and instability as family copes with uncontrollable adolescent behavior
"he started doing drugs, dropping out of school, being manipulative and defiant [at home]”
Asking for help
Parents seeking support and direction from WT program
"I loved her enough to send her away 'cause I just couldn't deal with it anymore…I knew it was beyond me" (single mother-05-06)
Fear of the worst
Parents sense significant negative outcomes of their child's destructive behavior
"he was going downhill so rapidly that if something doesn't stop him then it will be the police, or something worse" (divorced father-13-06)
Parents described home environments and child behaviors that placed the child, their siblings, themselves and other members of the community at risk. From parent descriptions of behavior at pre-treatment such as “the continued chaos, running away and bold face lies” (mother-07-06) to one parent’s expression of exhaustion “his situation dominated just about everything that was going on in the family” (father-adopted son-1106), parents openly expressed a lack of “control” or “understanding” of their child’s behavioral and emotional situation. Parents’ asking for help was described as common by an admissions director and, in her mind, represented a key element in initial parental engagement in their child’s therapy as articulated in the following passage: 97
They are at a point where they’re willing to do whatever it takes to get their child some help…this is a last resort, they’ve tried outpatient, they have tried so many things and they’re really just grasping for any kind of help, so they’re pretty open to, you know, participating (admin-24-06).
Many parents expressed grave concerns for their children prior to admitting them to WT. From examples of rapid downward spiraling behaviors such as “he went from recreational use, which we thought was bad enough and we were trying to deal with, to stealing money to get his fix” (mother-06-06), to mental health issues and fear of self harm. For example, one father stated during his son’s treatment “he seems to have a real internal struggle here…that has been leading him to think suicidal thoughts” (father-1006). Parents expressed fears for their children’s well-being which clearly highlighted the crises experienced by many families pre-treatment. Meaningful Separation
The act of sending a child to a WT program was found to be critically important in the therapeutic process and is seen by a cross-section of study participants as potentially being the most significant element of the change process. Descriptive codes comprising the Meaningful Separation pattern code include (a) Drawing the line, (b) Significant change, and (c) Physical and emotional distance are presented in Table 11.
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Table 11. Pattern code Process: Meaningful Separation with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Drawing the line
Parent decision to send child holds significance in family structure
"that was really the only thing I could do…it [the family] had completely fallen apart" (mother-14-06)
Significant change
Temporary disequilibrium of adolescent and family dynamic
"it helped me realize how much grief I was putting up with…she really had control over me until I was given the peace" (single mother-05-06)
Physical and emotional distance
Distance from negative family and social influences or patterns
"he really needed that time away from his regular life, he needed that support system" (father-adoptedson-11-06)
Many adolescents enter WT programs against their will and have experienced a very decisive parental decision in having been sent to a treatment program. This element of “drawing the line” was expressed by parents as being “difficult” yet “pivotal” and necessary to many. Although often conflicted by the decision to admit their child without their input, most parents came to believe it was the correct action to take as expressed in this parent’s reflection that “maybe this implies we should have acted earlier…when do you make the judgments and how does this come to needing a transport service, well I don’t know, but in our case it did” (em-em-0-13, 2006). This depiction of a meaningful separation was generally expressed during pre-treatment interviews, although remained present for family’s not experiencing success with the WT intervention whose children 99
transitioned on to other residential aftercare facilities. The continued separation was seen as more conducive to reaching treatment goals than the adolescent returning home. Program therapists depicted the moment when parents decide to send their child as a key element in the restructuring of family dynamics, and as pre-emptive to the change process. One therapist expressed “when families get to the point where they feel they need to have an intervention, part of the change has already happened” (therapist-1706). Essentially, the child’s behavior is no longer tolerated in the home environment and the child is placed—sometimes by force, coercion or deception—into WT by their parents. Significant change in the family dynamic was expressed by program therapists and staff as beneficial to begin the therapeutic process with adolescents, while parents related the need for a significant change in the home environment and their child’s life. One parent’s story reflects her decision that lead to what she described as a “successful” intervention for her son: “psychotherapy, medications, weekly therapy sessions which he never, never took anything in therapy, and never attempted to try to apply it in daily living, it was a waste of time…we just figured we might as well try something really dramatic” (mother-02-06). Additionally, program therapists related the opportunity that this significant change can have in the parent’s relationship with each other (i.e., marital health) and the family dynamic. One therapist spoke of couples “re-engaging” in their relationships and of other family issues “bubbling up” and being addressed (therapist-1506). The most obvious facet of WT is the physical distance separating adolescents from unhealthy and negative influences—environments, interpersonal dynamics, 100
substances—and the emotional space afforded by the physical distance. While many parents referred the benefit of “physical location” and “isolation” factors in their child’s treatment, one parent clearly identified it as the key to his son’s success when asked in retrospect what he felt the most beneficial program element was for his family during treatment: Oh, I think definitely the number one thing was, what you would call the separation from the environment…he had to get away from the situations that were enabling him to do this [use and deal drugs], and I guess that’s no secret why they do the wilderness part of it (father-11-06).
Emotional distance was described by therapists as providing families an opportunity to look at and discuss issues through an intermediary—the therapist. This was an important process for families when they may be incapable of having a conversation “that’s not threatening or you know, that doesn’t result in some huge emotional battle” (therapist-19-06). Program staff can facilitate discussions around these issues with parents and adolescents separately with less emotional intensity and can move them toward new ways of communicating and being in a family. Additionally, at times of family participation in the WT program, staff and therapists offer a supportive and safe environment for families to continue discussing difficult issues. Therapeutic techniques utilized intentionally in WT re-create family dynamics (e.g., transference, parental role modeling) in separate, conjoint and multi-family settings often providing learning opportunities for individuals to better understand their contributions to the family dynamic. Therapists and clinical teams spoke of attempts to capitalize on those moments 101
of transference that re-occur in the intensive family-like setting of WT groups. A number of adolescent clients referenced the “family-like” climate of their group during WT treatment observations suggesting the role the therapeutic “family” may play in their change process while separated from their actual family.
Family Issue Parents are required to participate in the therapeutic process upon their child’s admission to WT. From program philosophies supporting mandatory family participation, to recognition of parental and child roles in the family dynamic, behavioral and emotional relationships within the family system are focal points of treatment. One key distinction between CFWT and AAA in this regard is parent’s required attendance at CFWT upon their child’s admission, but not at AAA. Additionally, AAA parents are required to attend AAA for three and a half days at their child’s discharge while CFWT parents attend another single day as previously described. Descriptive codes comprising the pattern code Family Issue include (a) Family involvement, (b) Not alone, (c) System awareness, and (d) Homework are presented in Table 12.
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Table 12. Pattern code Process: Family Issue with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Family involvement
Programs require family participation, beyond identified patient model
"it weeds out the people that won't go and that, so you have a level of commitment" (father-10-06)
Not alone
Family experience is normalized with other families present
"I feel a little more comfortable with it knowing there are other families out there going through something I am" (father-12-06)
System awareness
Families recognize interconnectedness of behaviors and attitudes within family system
"and realizing, you know, that I said things to her that built her anxiety" (singlemother-05-06)
Homework
Parents put effort into change process at home
"the work we did on our end as parents was really good…assuming someone else is going to fix my kid is, that's not gunna happen" (mother-03-06)
Family investment in the therapeutic process, and change in the family, was identified by program staff as a key factor in creating “sustainable” change. One program therapist articulated this belief that extends beyond the “identified client” to the family in saying “it’s the relationship that needs to be different to succeed, not so much that the kid has to change, it’s the relationship [between child and parents] that has to change” (therapist-23-06). Programs believe that participating families want to educate 103
themselves and do what they can to alleviate the crisis in their families and need to be provided meaningful opportunities to do so. Families engage in WT along with the families of other clients. For AAA parents this occurs over the last four days of their child’s treatment, and 2-3 single days for CFWT parents upon admission, at the end of 3-weeks and sometimes again at the end of 7 weeks if extended expedition is warranted and agreed upon. This shared experience was described by parents post-treatment at AAA, and pre-treatment and post-treatment by parents at CFWT, as “comforting” and a “relief” in knowing that they were not alone in what their family was going through. One program administrator expressed the accelerated bonding of parents who meet in their program. He stated “one of the most common reactions we get from them [parents] is, ‘I can’t believe how open we were so quickly, with these people who were strangers’ ” (admin-22-06). One parent expressed relief in the shared experience of what he considered a drastic intervention in stating “I feel a little bit more comfortable with it, knowing there are other families out their doing the same, going through something I am” (father-12-06). Awareness of the interconnectedness and affect of individual family member’s behavior and emotions within the family dynamic generally increased during the WT intervention. One parent from a conflict-ridden divorced family expressed his desire pretreatment for better inter-family communication to better support his child’s change process. He said “I hope we can come together on this so that we can give him [our son] some consistency…that we can collectively find a way that he can find comfort between his parents and feel safe” (divorced father-13-06). By the time families are reunited, program staff hopes to have shifted families from the blame of individuals to a “family 104
systems” thinking approach—the belief that “we are all in this together.” One program therapist described efforts taken to achieve this in saying that “most things we do in the field are geared towards the kids recognizing how they impact their families and vice versa” (therapist-15-06). In consultation with their child’s WT program therapist, parents complete assigned tasks related to their child’s treatment plan as well as work with therapists in their home communities. This “homework” was expressed at two-months post-program by one parent as critical for success in her family because: It’s so hard to just get thrown back into the same dynamics without a little bit more practical help, I think that’s why we are continuing to do more outside therapy, we think that there’s going to be huge benefits to the family for that (mother-03-06).
One program therapist outlined to parents the need for early and sustained work during and following WT. The program can work with the family to set the stage for the child’s success and “get that ball rolling” but also recognize and reinforce with parents that they need to generate some momentum themselves if they you really want it to work when their child comes home. Meaning
Family members expressed a wide range of significant and impactful experiences from participation in WT. Patterns describing Meaning of family experiences include (a) Mixed emotions, (b) Touchstone experience, and (c) Abrupt transitions are presented in 105
Tables 13, 14 and 15 and are further articulated with associated descriptive codes, definitions and examples. Mixed Emotions Families experienced myriad emotions throughout their WT experience, often ranging from pre-treatment tension due to idealized outcomes to post-treatment concerns for their child’s failure. Descriptive codes comprising the Mixed Emotions pattern code include (a) Hope and fear, (b) Guilt and shame, and (c) Anticipation are presented in Table 13. Table 13. Pattern code Meaning: Mixed Emotions with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Hope and fear
Desire for positive outcomes blended with fear of pushing child farther away
"I was worried he would hate us for life, he walked away thinking this was awesome" (mother-14-06)
Guilt and shame
Parents concern for child's "as a parent you just don't and communities reaction to know what you are doing, sending child to WT it's very disconcerting to take that step" (father-adopted son-11-06)
Anticipation and happiness
Reuniting and seeing children is often overwhelming and preceded by heightened anxiety
"I was nervous and excited…it was like giving birth all over again, it was like getting [my son] back" (mother-02-06)
From initial pre-treatment contact with WT programs to transition periods posttreatment, parents often expressed a range of emotions such as hope and fear. While 106
desiring good results, many parents expressed fear of negative repercussions for admitting their children to a WT program, often against their will. One parent described hesitation in making the final decision when stating “I was dragging my feet because I couldn’t imagine doing that kind of intervention so, and, that is sort of how we arrived here” (father-12-06). While often rewarded with eventual positive outcomes in their child’s response to WT program interventions, a range of emotions exist, and fluctuate throughout the duration of the program. Post-treatment, family’s hopes and fears of child anger and retribution generally shifted to hope for a positive future, and fear of relapse as depicted in this parent’s reflection two-months post-treatment regarding his son’s return home. I guess time goes on here, as we get another two or three months, or maybe a year behind us, we’ll know more about how obviously it turned out, and we, we’re anxious just to see some other areas of development for [our son], ah, beyond sobriety (father-11-06). One program administrator described his observations of parental concerns for being judged for sending their child away or their inadequacies as parents, in the following passage: And we have, a lot of our parents come, and they say, you know, I’ve had no one to talk to about this, and some of them felt a lot of shame and a lot of guilt, and, um, we’ve had parents who’ve had, who’ve, completely hidden the fact, from their community that they sent their child to a wilderness program. So, I feel like that’s lessening, you know, more and more its becoming more accepted and so, people are more upfront about it (admin-22-06). 107
While not often expressed by parents as “guilt” or “shame” specifically, many parents expressed feelings during their WT involvement of inadequacy in dealing with their “family problems” and having to defer to “outside” or “professional” help. This type of commentary was often reflective and shared with some discomfort and personal disappointment by parents. Anticipation and happiness was most often seen and heard just prior to family reunions with their child participating in WT. Behaviors associated with elevated levels of stress were also observed preceding family reunions at both programs. Parents and siblings were taken to a field site where they were to meet with their children after 3-9 weeks of WT treatment. On one occasion the researcher noted “an air of anticipation exists among parents, now nervous about seeing their children and being unsure of what to expect…reflective solitude and nervous laughter pervade” (obs-a-33-06). The physical “re-joining” of families following that observation was experienced by the researcher as an overwhelmingly powerful and positive experience with smiles, laughter and tears. One parent, when asked what it was like to reunite as a family expressed she “was so surprised, cause I was so worried that (laughs) we wouldn’t [get along] but, we actually did” (singlemother-01-06). Touchstone Experience Participants identify the depth of their WT experience as highly impactful and these experiences are seen by parents as significant milestones and signs of future success. Descriptive codes comprising the Touchstone Experience pattern code include 108
(a) Connectedness, (b) Demonstrate potential, and (c) Place of strength are presented in Table 14. Table 14. Pattern code Meaning: Touchstone Experience with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Connectedness
Adolescents bond with other participants, staff and wilderness. Parents felt support from other parents
"sitting around the camp fire, and he was telling me all the constellations, there was time to talk, to really connect" (singlemother-01-06)
Demonstrated potential
Family recognizes change "I see some real changes, in their child and sees future maybe he really did look at potential himself, I would have never believed this to happen" (mother-14-06)
Place of strength
Adolescents and family can draw on memories of experience throughout life
"he may never camp another day in his life, but the fact that he realized that there shouldn't be anything out there he can't get through, um, that's going to be a tremendous boost to his recovery in my mind" (father-12-06)
Connectedness describes two facets found: (a) the connectedness of participants to program elements (i.e., staff, other participants, process), and (b) the connectedness observed and described by participants to the places they had traveled in. Many adolescents and parents referred to the nature of group bonding that took place in the field and at transition periods with families. One parent at post-treatment recounted his 109
initial meeting with other parents at CFWT and recognition of the group that they had become, although hesitant to acknowledge its direct effect on him until he articulated it to the researcher in the following passage. I know that there is sort of a bond between the group, that you would think you are developing that is not really what anybody cares about cause this (family involvement) is not about a group, it is not about any kind of bonding [for parents], but I guess you have to establish a bare minimum level of group, even if they don’t end up being a group, so maybe that’s the point, maybe that really happens (father-10-06). The role of physical activity and reflection previously described in these findings relate closely to this descriptive code in that it is not really clear what adolescents in WT “connect” to, but a number of program elements mentioned were observed as holding special relevance to the participants. This phenomenon was acknowledged by parents and program staff as somewhat “mythical” or “mysterious” and that “it” happens “out there.” Clearly, further inquiry is needed to understand the contribution of many potential latent program variables. Change occurring in participants and their families is demonstrated through behaviors and interpersonal communication. Recognition of future potential became more apparent to parents in WT programs as treatment progressed. As one program therapist related a common parent experience following the WT intervention: They felt like it was just, they could trust their kid for that moment for the first time in a long time, and even if that doesn’t last, just having another experience of that is credibly powerful and that’s one way for families to remember again the 110
joys of parenting, the re-establishment of relationships with their kids is pretty profound (therapist-17-06). Additionally, parents often expressed this demonstration of child and family potential as a benchmark, which although they may regress from, was a standard they aimed to maintain and possibly exceed. The manifestation of this potential is further expressed in the pattern codes of the following Outcome section. While some adolescents struggle post-program with issues previously experienced, a common theme from respondents at two-months post-program was that of the ability to utilize wisdom gained during their WT experience. One parent spoke of WT participants in general when sharing the experience of her child’s ability to draw strength and knowledge from his WT experience. I think it definitely enlightens them…they can see negative behavior, they can see destructive behavior…when you’re talking about therapy 24/7 for seven weeks, you can’t help [but] walk away with a different perspective…I can’t imagine all that information passing thru them didn’t get collected in some way, shape or form (mother-04-06).
Abrupt Transitions Entering and exiting the WT program environment was found to be challenging, logistically and emotionally, for parents and their children. Descriptive codes comprising the Abrupt Transitions pattern codes include (a) Involuntary participants, (b) Re-entry challenges, and (c) Skill testing are presented in Table 15.
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Table 15. Pattern code Meaning: Abrupt Transitions with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Involuntary participation
Adolescents often admitted to program against will and with transport services
“he didn’t want to say goodbye, he didn’t want to be near me…I wanted him to be ok with it” (mother-09-06)
Re-entry challenges
Significant adjustments experienced by adolescents and families post-program
“the first week home…it was like standing on the edge of a freeway, and trying to jump on without an on-ramp” (father-11-06)
Skill testing
Frustration in adjusting to new patterns of communicating and being within family system
“he’s actually getting frustrated with us because we’re not able to do it [communicate] in the manner that he is used to” (mother-02-06)
Many adolescents enter WT involuntarily and often with the assistance of “escort” or “transport” services contracted by the WT programs or parents to bring the child to the program location. The decision to use these services was expressed as “uncomfortable” and “disconcerting” by parents although often considered “the only way” they could get their child into treatment. While many parents moved from guilt to confidence during the WT intervention, and relief in their decision to admit their child this way at post-program, adolescents often expressed anger first, and later levels of acceptance of their parent’s decision. While some parents were able to admit their children without outside help, many adolescents still did not “choose” to attend. One 112
parent expressed “my son went willingly, he had some advanced notice, although he did not have an option” (jm-pm-f-21, 2006) while parents in higher crisis situations were willing “to do anything within [their] power to help him” and circumstances often necessitated outside help. The transition period back into home communities or into residential aftercare programs post-treatment was often described by parents and program staff as just as difficult as the initial transition of sending children to WT. For those adolescents returning home, and not on to residential treatment or education programs/schools, parents establish a rigid behavioral contract for their children. This process attempts to carry on highly structured daily routines and expectations established for adolescents during WT. One common re-entry challenge for parents was expressed as a sudden and unsupported experience. One parent described his experience of the “finality of the relationship with [WT program]…I mean there’s no follow-up…had we not set up this outpatient program it would seem like we were just swimming on our own” (father-1106). While WT programs highly recommend home therapists and other post-program supports, they do not work with families beyond the time adolescents depart from the program. Another parent spoke of the two rollercoaster months following her son’s return home: “Our worst week, you know, the second week was horrible, really bad…the coming back home excitement goes away…couple of good weeks…2 or 3 that were really bad again…then things kind of settled down in the last 3 to 4 weeks” (mother-0306). Adolescents going on to residential aftercare had their own struggles with new program settings (e.g., change in structure and staff relationships) although their parents
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described a relief in the continuity of standards, routines and consistency in their children’s care similar to that experienced in WT. Skill testing describes the experience of parents and adolescents upon their return home related to ways of communicating and being in a relationship. While adolescents experienced living in a highly choreographed therapeutic environment, parents worked with the material they were provided and with home therapists with available time and motivation. One result of this disparity was frustration. While more often that of the adolescents, frustration was also expressed by parents as their social and emotional skill development was different from that learned by the adolescents in WT. Program observations showed adolescents “coaching” and leading parents in many aspects of communication skill development. While a very “paradoxical” and intentional process from a structural family therapy perspective, allowing parent-child role reversal, the level of communication training received by adolescents was often observed at AAA, and reported by CFWT parents at home, as outweighing any new skills acquired by many of the parents. This reality lead to some adolescents expressing frustration post-program when their parents, as one adolescent expressed, were “not able to do it [communicate emotions] in the manner that he’s used to” (mother-03-06). Outcome Findings describing and demonstrating outcomes of family involvement in WT range from the recognition and impact of individual personal growth, opportunities for families to start anew, and that WT is a stabilizing, not curative, intervention. Patterns describing outcomes of family involvement include (a) Sense of self, (b) New
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beginnings, and (c) Not fixed are presented in Tables 16, 17 and 18 and are further articulated with associated descriptive codes, definitions and examples. Sense of Self Parents and adolescents describe recognizing gains in self confidence and personal conviction of their children and the related effect on their family. Descriptive codes comprising the Sense of Self pattern code include (a) Calm and Focused, (b) Assertive Communication, and (c) Pride are presented in Table 16. Table 16: Pattern code Outcome: Sense of Self with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Calm and focused
Adolescents behaviors are stable and demonstrate increased clarity of mind
“when I got home I was really calm and contained, and I resisted anger many times, and I talked out my problems” (adolescent male-14-06)
Assertive communication
Adolescents demonstrate openness and ability to identify and articulate emotions and dysfunctional behavior patterns
“when he talked to me, he didn’t raise his voice… [we communicated] without getting angry” (mother-02-06)
Pride
Family recognizes level of accomplishment and journey endured
“I just saw a child that felt secure…felt really good about what he was able to accomplish during that time” (single mother-09-06)
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Both parents and adolescents expressed being more calm and focused during, and more often following WT programs. This outcome was observed during family reunions and program activities that required open and honest communication between parents and their children. Even when expressing dismay with unhealthy family dynamics or making disclosures of past behaviors, adolescents generally displayed an ability to identify problem behaviors clearly and articulate their feelings in a healthy manner. Parents described their children as “calmer,” “more reasonable” and “relaxed.” One parent related changes occurring in her son’s body language supporting this outcome. She was surprised by her son when he “looked me right in the eye when he talked to me, which he hadn’t done before” (mother-07-06). Assertive communication was also apparent among adolescents in WT programs. Adolescent requests for family and community support, change in the home environment and apologies for previous actions and behavior, demonstrated a high degree of confidence in speaking to their parents in public and private settings. One parent shared her perception of her son’s WT group and their ability to discuss difficult issues openly and honestly. It was really, really nice to see, you know, aside from obviously having such a bond, um, but it was, they were, I don’t know how to describe it, they were, all very confident when they were interacting with each other, I mean they were just themselves (mother-02-06). The element of pride was described by parents, program staff and clearly observed during program activities and during post-treatment and two-month posttreatment interviews. A sense of “great accomplishment” was often articulated by some 116
parents and program staff as the completion of a “quest” or “journey of self discovery,” while adolescents were observed describing the experience as overcoming physical and emotional challenges resulting in self-confidence and pride. As one adolescent who had great fears of not being able to physically complete her WT program exclaimed “I am here, I did it, I lived” while later relating that her greater accomplishment in WT was overcoming her pattern of living in fear and now taking pride in facing her fears head on. New Beginnings Parents, adolescents and program staff articulate a sense of rejuvenation from the family’s experience, providing the space and energy to start again with new skills and knowledge. Descriptive codes comprising the New Beginnings pattern code include (a) Clean slate, (b) Inspiration, and (c) Reorganize family roles are presented in Table 17.
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Table 17: Pattern code Outcome: New Beginnings with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Clean slate
Family recognizes the opportunity to “start over”
“the program rounded off what he wanted and intended to do, you know get the foundation set…we felt like it was a good springboard to take him home” (father-11-06)
Inspiration
Families see, hear and feel what healthy family function is and know it is possible
“for the first time in a along time I saw the truth and essence of my son…for that small glimpse into what he could become, I am grateful” (singlemother-09-06)
Reorganize family roles
Parents re-establish authority and family roles are redefined
“what it has done is in fact, it has changed the family dynamic” (mother-07-06)
One program director expressed his belief that the single greatest indicator of success in adolescent interventions is not how well child does in program, but the significance of changes occurring in the home environment. The manifestation of this belief was observed in practice when program therapists recommend parents change their child’s school and friends when necessary (i.e., when closely associated to problem behaviors), address issues of alcoholism and child access to alcohol in the home, improve marital relations and to invest in other areas of family and community life. While parents do what they can to prepare for their child’s eventual return home, the work requested by 118
program therapists and completed by parents was recognized by adolescents and provided the appearance of a “fresh start” and that their parents “invested” time and energy and were not expecting them to change alone. When back at home, many parents expressed that the families sense of “renewal” was often challenged by “temptations” and “old patterns.” Parents depicted both positive and negative outcomes following WT as a period of “adjustment” although the sense of renewal and new beginnings remained intact even after their time apart. The acquisition of new skills and knowledge was described as assisting in the maintenance of change within the family. Parent’s expressed a level of inspiration upon reuniting with their children. From “missing them” to recognizing significant “shifts” in attitudes and behaviors, parents described feeling encouraged and hopeful, although often cautiously, for the future. While parents expressed hope for positive change in their children’s well-being, a longing to regain a child they remember differently was apparent. Some parents expressed a desire to “rediscover” child qualities lost either over the years or during their more recent family’s difficult times. As one mother stated when admitting her son “I hope he can, you know, (pause) regain his peace, cause he is not very happy right now” (singlemother-09-06). The reorganization of family roles is intentionally planned for by WT program therapists through structural and systems theory approaches to working with the family unit. The following passage articulates these practices and accounts for an outcome later described by parents. We certainly look at a family system/structural family therapy perspective…where in this current society a functional family has pretty strict 119
boundaries, pretty regular boundaries between parent unit and kids, and that when those structures/boundaries get askew that things go haywire and people get anxious, and angry and so we advocate for re-establishing some natural authority between adults/parents and kids and so part of creating a milieu that has strong leaders/ parent-like leaders who help provide natural logical consequences but are also loving and caring while providing good boundaries, in an attempt to establish or re-establish a, what we consider, a healthy family structure (therapist-17-06).
Parents are supported in developing a formal and rigid plan for their children to adhere to when they return home. Some parents expressed an increase in their vigilance in their effort to maintain positive outcomes gained during the WT intervention. As one parent stated “the whole family is focused on [their son] and want to make sure that, you know, he keeps along the right path here” (father-12-06). This act of increased supervision and attention for their children was interpreted as a re-investment in parental roles such as assuming greater input in decision-making for their child, which may have previously been given up or lost to the child before the intervention. Not Fixed Most participants interviewed in this study demonstrated an understating that WT does not “fix” children. The WT intervention is recognized as effective in addressing core issues and establishing a strong base for families moving toward accessing more long-term residential or community-based services. Descriptive codes comprising the
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Not Fixed pattern code include (a) Stabilization, (b) False Environments, and (c) Systems of Support are presented in Table 18. Table 19: Pattern code Outcome: Not Fixed with descriptive codes, definitions and examples of coded responses Descriptive code
Definition
Example of coded response
Stabilization
Recognition of intervention as stabilizing and not curative
“I don’t think this is the end of his work and definitely he has to go on to some kind of aftercare program” (singlemother-01-06)
False environments
Change experienced at home or in WT environment do not reflect reality
“we’re still at a point where we are trying to find those roles on our family…that’s the hardest time for us, when he first came back, I knew it would be tough” (mother-03-06)
Systems of support
Need for home therapist and network of support for maintenance and further growth
“if you really want it to work when your child comes home then you need do this [build support] to make it sustainable” (therapist-17-06)
Whether the child in treatment was moving on to residential boarding schools, treatment programs or returning home, most interviewees described WT as a stabilizing, and not a curative, intervention. Program staff ensure to dispel any such belief that parents may have about what outcomes the program may facilitate with their children. One therapist shared his approach in talking frankly to parents about what their treatment program can realistically offer the family. 121
We are going stop the negative pattern that’s going on here, provide you and your child with an assessment of how long the road back is going to be and what sort of services and support you are going to need in order to return to some sort of equilibrium (therapist-16-06).
This approach and belief system was apparent in program practices with adolescents, parents, intact families and multi-family groups at both programs. Problem recognition, educational processes to further develop skills and relapse prevention were common activities in the WT process and provided participants with “grounding” experiences to build on. WT was observed as providing a direct and significant reduction in family crisis and the skills and encouragement to maintain the momentum that has been afforded by this experience. The wilderness has been described as an effective environment or “milieu” for adolescent therapy; however, change experienced in WT remains untested while the child is separated from family and community life. One program therapist described the “two false environments” of a (a) child in WT, and (b) the family at home without the “child.” The WT experience and related outcomes are put to the test upon reuniting the family and reintegrating into their regular daily life. This “false environment” was described by one program field staff as a critical perspective for parents and children to understand. Parents shared awareness of this and also of their skepticism, and fear of perceived change that might not manifest in the home environment. Unfamiliar and simple outdoor environments were observed as allowing for exploration of new skills and attitudes to be practiced. While maybe not directly translating into change in behavior, attitude and 122
emotional state, these newly acquired skills were described as “life long” and available to be used by adolescents and their families in their future post WT. One parent shared his son’s efforts at home two-months post-program to follow through on commitments he made with conviction during his WT experience. He expressed “he’s making attempts to stay away from them [negative peers]…he’s going to be tested constantly, because, unless we move away from the area, these people will still be around” (father-11-06). Systems of support were found to be necessary during and following WT to ensure maintenance of change in WT participants and their families. Parents described establishing new relationships with local therapists and services, or maintaining existing ones. While outcomes were generally positive, families resorted to a variety of support services depending on how their child was doing and their level of concern for “relapse” or further problem behaviors. Following WT, some parents expressed feeling a bit lost and in need of further assistance. One parent who was concerned of relapse established a network within his community to assist with his son’s transition home including an outpatient program and regular meetings with their family counselor. Programs clearly articulated the need for community support during and post-program to parents upon admitting their child to WT. Program directors and clinical directors recognize the need for long-term support from community-based service providers and assist families in establishing this system of support as early as possible in the process. Two Illustrative Vignettes Vignettes were chosen to represent diversity of (a) family dynamics, (b) client presenting issues, (c) program practices, and (d) related family experiences in WT while further illustrating qualitative findings of the study. One family from each WT program 123
was chosen from the 14-family qualitative study sample. They were chosen purposively to provide rich understanding of findings, and similarities and differences between programs. Family and program features are presented in Table 19 and provide the context for their descriptions. Names have been altered to protect confidentiality. Table 19. Vignette family compositions, program attendance, presenting issues, adolescent and family outcomes and two-month post-treatment status Family
Jackson
Program
Aspen Achievement Academy Single mom Limited contact with father Two biological sons
Family composition
Program attendanceadolescent Program attendancefamily Presenting issues
Outcomes-adolescent
Outcomes-family
Post-program realities
Walker
Catherine Freer Wilderness Therapy Expeditions Married couple Limited contact with biological mother Two adopted sons 8 continuous weeks in WT 7 weeks in WT 3 week trek and 4 week extended expedition 3.5 days at discharge 1 day at admission 1 day at 3 weeks 1 day at discharge Substance misuse Substance abuse Dropping out of school Dealing drugs Defiance & manipulation Depression Non-communicative with High risk social behaviors mother on presenting issues Kept much of problem behavior from parents Abuse disclosure Stabilized Acceptance of work ahead Problem recognition Stabilized behavior Committed to change Open and honest Genetic predisposition to communication with mother alcoholism acknowledged More assertive parenting New family and parenting Improved communication skills Positive outlook Improved communication Adolescent in therapeutic Adolescent returned home boarding school Deals with constant Sibling safer and more “temptations” engaged with mother Family monitoring
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The Jackson Family: Aspen Achievement Academy Sara Jackson admitted her son to WT following a couple of years of what she described as “downward spiraling behavior” of her son Matt. Matt was cutting classes, using drugs and alcohol more frequently and being defiant and manipulative in the home. Sara believed that a recent move between school districts may have brought on these changes. Matt had attended individual therapy for more than a year and that “didn’t seem to help.” She knew that Matt was fond of the outdoors and felt that WT may be an option “for him to kind of re-assess his decisions lately.” While he did agree to attend WT, it was clear that Matt did not have a choice and it would be easier if “he went willingly rather than with a transport service.” While being “pretty confident in the program” to help her son, she also lamented on the fact that her child was in crisis and that she couldn’t “directly assist him with that.” While not having the “professional capacity” to help Matt, Sara also shared that Matt does not want to relate to her at this point anyway, so outside help seemed most appropriate. While Matt appeared to settle into WT as indicated by letters home, Sara began the on line educational assignments from Matt’s program therapist and described her role in the process as “to communicate with her son” and “to just be there, no matter what…for him.” Sara described her perceptions of WT early on in the process and stated that she didn’t see it as “a long term fix” but expressed her hope for Matt to address key issues (i.e., substance use, defiance) and that his time away was very important for both of them to work on themselves. She expressed relief in not having to deal with the “havoc and chaos” he used to create while paradoxically experiencing a “sense of loss that he is not there.” 125
Early indications from letters and therapist reports suggested Matt was engaging in the therapeutic process, enjoying the wilderness environment and having time “by himself to think about himself” without “all the distractions.” These early reports provided Sara with confidence in her decision to send Matt to WT. She believed that the combination of the environment, physical activity and therapy would be ideal for Matt. At the 8-week family reunion (i.e., Sara’s first visit to AAA), Sara was clear in her decision—recommended and supported by Matt’s therapist—to send him on to a therapeutic boarding school. With this decision a heightened anxiety existed as to how her son would react to the decision was overwhelmingly present in Sara. Upon arriving in Loa Utah and meeting with other parents, Sara was obviously fearful of Matt’s anger and resentment as they had both seen WT as a summer intervention and that Matt would return home upon completion. The realities of the depth of trauma disclosed by Matt in WT and the timeframe to process and resolve these issues indicated further treatment— the boarding school in which he had recently been enrolled. The actual reunion was “scary at first” but turned into an experience that Sara described as including discussions with her son that were “like we had never had before” and that they “really connected.” The immediate issue between Matt and Sara upon reuniting was the issue of boarding school and Matt tried, although without his characteristic anger previously seen by Sara, to talk her out of her decision. Sara’s response of holding her ground on the decision was critical, as she reflected “he realized that I wasn’t changing my mind, he kind of got a little bit better about it.” By late that evening Matt was resigned to the decision and was “making jokes about it” and more interested in hanging out with Sara during their staff and therapist-supported two-day “family solo” in the high desert. 126
Another significant experience for Sara and Matt occurred during a “family sculpture” exercise where Matt portrayed his family using other group members and their families. Matt’s intention was to create a family portrait of actors, actions, and meanings through silent “sculpting” of people and props. A great difference in interpretation existed between the two when Matt placed the characters representing his parents an equal distance away from himself in the sculpture. For him, this visually represented their divorce and his desire to know both parents. For Sara, this was perceived as grossly inaccurate as she is the sole provider for her son and considers her ex-husband negligent and absent in his responsibilities as a parent. Sara was visibly upset by this representation. It was in the processing of this experience by the therapist that Matt began to see his mother as “vulnerable” when he had always seen her as strong and capable. This also caused Matt to express his level of appreciation for all his mother had provided him since his father left years prior. Later discussion between the two around the fire during “family solo” was described by Sara as meaningful and “a really good time.” Two months WT post-program, Matt was in residential boarding school and Sara shared reflections on her WT experience. She described time spent in the desert camping as providing her and Matt with a “meaningful and understanding relationship from that point on” and that she saw it as the defining moment of her involvement with the program. Further, the relationship with her son’s therapists was “critical to the process” as Sara described her longing for “more information” and her “faith in that therapist” to provide her with an accurate understanding of what is going on and to alleviate concerns as they arose. Sara had received weekly email updates and generally spoke to Matt’s 127
therapist at least once each week, but felt the lack of direct contact increased her desire for more information on how he was doing. Sara was understanding of the logistics of WT, but was critical of the communication channels between her and her son through letter writing. Matt had sent some letters that were received “clumped together” and Sara found it difficult to respond when the nature of each letter changed and demanded different responses as they were written over a period of a week. Overall, Sara concluded that the WT intervention allowed both her and her son to “come clean on, you know, why we did things, who we are, and where things ended up” and that she doesn’t believe that Matt could have made this much progress in a “clinical environment.” While Matt expressed being “scared of the work ahead,” his behaviors are stable and he is, at the time of writing, experiencing success in another structured therapeutic environment.
The Walker Family: Catherine Freer Wilderness Therapy Expeditions Steve Walker and his wife recognized changes in their son Jeff’s behavior when he was 15, and by the time he was 17 he approached them and asked for help with his addiction to drugs and alcohol. As an adopted child, the Walker family saw Ben’s declining participation in extra-curricular activities and struggles with academic work as potential learning difficulties. This new knowledge of the seriousness of their son’s addictions was a surprise to them as they had only suspected Jeff of experimenting with substances and that he was slowly “losing interest” in some of his regular activities. Within weeks, a school drug and alcohol counselor had recommended an inpatient treatment program and Steve and his wife had Jeff admitted. Three weeks later, Jeff had been discharged from the inpatient program for behavioral reasons and the decision to 128
admit Jeff to a WT program was made. Not wanting Jeff to return to his peer group or patterned behaviors, the Walkers provided 24-hour supervision to Jeff for four days until they could place him in the Catherine Freer WT program. Jeff’s parents felt he was a “logical candidate” for WT as the inpatient program contained elements “too close” to the environment in which Jeff had made poor decisions. This included behaviors and attitudes similar to his peer group and inappropriate use of unstructured time. The Walker family didn’t know the full extent of their son’s issues until a few weeks into the wilderness therapy intervention. Disclosures of violent and high risk behavior surfaced as Jeff became more engaged in the treatment process. He told stories of failed drug deals and extorting money from other adolescents to support his drug and alcohol habits, and obvious patterns of substance addiction were apparent to counselors. While Jeff became a “leader” within his adolescent WT cohort with his ability to “articulate his struggles of recovery,” he not would not acknowledge his social and peer structure that his treatment team indicated would also need to change. This became a focus for his treatment in following weeks. Steve Walker described these early reports as “making a difference where the inpatient program didn’t seem able to” but long-term attitudinal change away from substance use was still a present concern. While Jeff attended WT, the Walker family engaged in the family education material provided by the program and began to establish their “system of support” at home. As Steve related “we need to be ready for that (Jeff’s return home) or if he goes into an extended program, he still has the outpatient (services) ready for when he is finished…so it’s a bit like doing homework here.” While missing their son and some of his stronger positive characteristics that had been overshadowed by negative behaviors in 129
recent years, Steve and his wife also realized that “there was no time for each other” and that it “was good to get everybody separated” to “get him the help he needed” and allow them to look after the “details” for the family and their own marital relationship. While still concerned about Jeff’s “level of maturity” and fearful of relapse, the Walker’s attended the final family meeting at the end of seven weeks of WT treatment and returned home with Jeff to what Steve referred to as a “stronger family.” A dichotomous relationship existed within the family dynamic as Jeff was encouraged to “take more responsibility” and “be accountable” for his sobriety and behavior, while the family, including Jeff’s younger brother, became vigilant in their support and monitoring of Jeff. Jeff expressed similar concerns of relapse, but also of hope. He stated that he “overcame fears” when climbing and rappelling off cliffs and that he was able to generalize that learning other parts of his life. He also expressed a belief that he can now overcome anything he perceives as preventing him from success. This belief was tested within the first month home as Jeff returned to his job at a fast food restaurant, and quickly realized the “temptations” of substance use were too present in that environment. Without parental or home therapist influence, Jeff quit his job as he believed it compromised his sobriety. The Walker family had serious “apprehension” about whether or not they had “made the right choice” to send Jeff to WT. In leaving treatment, Jeff’s problem recognition and articulated desire to remain sober and accept responsibility for behaviors that had caused harm to his family was apparent. This expressed and observed change in Jeff’s attitude and behaviors relieved his parent’s concern, further supporting their initial decision to admit their son to WT. While Jeff may or may not represent the normative 130
level of readiness for change of all adolescent in treatment with substance use issues, his father recognized significant shifts in his son which occurred during his time in WT. It was the first real, ah, rehabilitation or recovery work that seemed to get to him, or seem to work with him. And all the stuff that we had heard from the counselors prior to meeting him at the end of E1 (first 3-week trek), ah, made it sound like, wow, there’s a tremendous recovery here, and then when we actually saw him, ah, at the end of the first meeting, ah it was unbelievable, you know, the change that had gone through him in just the three weeks (Steve Walker-f-3-1, 2006).
Summary of Qualitative Results This section serves to provide a brief synopsis of qualitative results. Data collected provided an overall picture of family involvement and related experiences in WT. Themes presented were considered representative of the sample and, occasionally, were countered or tempered by varying degrees of difference in participant responses (Miles & Huberman, 1994) in effort to provide an accurate portrayal of the family’s experience and WT programmatic realities. Family involvement in WT begins for most parents, with a phone call to programs during a period of heightened family crisis. This action was generally seen as a response to the family and community resources inability to meet the needs of a child at risk of considerable harm to self or others. Adolescents most often presented with behaviors including serious drug and alcohol use, criminal activity, school truancy, mental health issues, running away and non-compliance and abusive behavior in the family home. While most families experienced a sense of helplessness in asking for outside help, and a 131
significantly impactful intervention, program staff and their involvement in the WT process appeared to relieve most concerns. WT program’s family involvement is guided philosophically by family systems theory and a multi-dimensional approach to therapy, and—although not always explicit— elements of a holistic approach incorporating a variety of educational and therapeutic elements. The wilderness environment itself was found to be a contributing factor in the WT treatment philosophy but was not made clear beyond references to Ecopsychology and nature’s role in rites of passage and rituals clients may have experienced on program. Clearly however, is the program’s beliefs that change in the family at home during the child’s time in treatment (i.e., recognition of family’s contribution to problem behavior) are often the strongest predictors of long term success for the family. WT programs provide families with direct involvement in the treatment process, counseling support, multi-family educational experiences, psycho-educational material and direction on home and community decisions regarding their child’s treatment and aftercare plans. Concurrently, adolescents are in program addressing family issues and communicating with their families through therapists and written correspondence. Parents expressed a high degree of trust in the WT programs, referencing the physical and emotional safety that the wilderness environment offered their children, program’s professional approach to assisting with family crises, the family-based approach, and the physical challenge and reflective qualities of the intervention. Families reported a sense of newness to the family dynamic and that the intervention provided stability and a reorganization of family roles previously displaced by crisis. Families recognized the reality of having to integrate change and learning into 132
more conventional environments of home and community, but were generally optimistic about the future following the intervention. Transitions into and out of WT were found to be challenging for families. Those adolescents not ready to return home, also experienced another difficult transition into aftercare programs and facilities. While new skills and knowledge were challenging to integrate as a family, reports of more direct and assertive communication were common. Qualitative findings are further elaborated on in Chapter five through an integration/synthesis with quantitative findings which are presented in the following section. Quantitative Results
An overview of adolescent participant demographics is first presented including gender, diagnoses, treatment lengths and sample distribution between programs. Results of quantitative analysis follows addressing three specific research aims: (a) to assess change in family function, (b) to assess change in adolescent outcomes, and (c) to examine strength of relationships between measures of change and program and client variables. Participant demographics Between June 15th and September 15th 2006, 184 adolescents entered WT treatment at AAA and CFWT. Of those, 132 agreed to participate in the study, yielding an overall study participation rate of 72%. Forty-five were from AAA and 87 were from CFWT. Additionally, one parent/guardian of each consenting adolescent was asked to participate in the study. Eighty-five parents consented to enter the study (AAA, 21; CFWT, 64) representing 74% of the adolescent sample. Adolescents asking to withdraw 133
from the study and the occurrence of unusable data due to participant or data collection error resulted in a loss of seventeen adolescent participants prior to analysis resulting in data analysis of 62.5% of the total adolescent sample. As per study protocols, no data were collected on non-participating adolescents or parents leaving participant response bias unchecked. Reasons for non-participation by parents included lack of interest and confidentiality concerns along with consenting participants who did not fully complete measures. Average length of treatment was 40.3 days (SD = 14.3). CFWT utilizes a threeweek expedition with possible four-week extended expedition model while AAA runs a seven to nine week continuous expedition model. AAA clients averaged 45.3 days (SD = 6.2) in treatment while CFWT clients averaged 38.3 days (SD = 15.8). Differences in treatment length were expected between programs and subsequently found to be statistically significant (t(113) = 2.24, p < .05) with a mean difference of seven days longer at AAA.
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Table 20. Frequency and relative percentage of participants by program, gender and age Aspen Freer Total
Frequency 30 85 115
Percentage 26.1 73.9 100.0
Aspen
Male Female Total
20 10 30
66.7 33.3 100.0
Freer
Male Female Total
53 32 85
62.4 37.6 100.0
Male Female Total
73 42 115
63.5 36.5 100.0
Missing Total
5 8 27 36 36 2 1 115
4.3 7.0 23.5 31.3 31.3 1.7 0.9 100
Program
Gender
Age
13 14 15 16 17 18
Mean SD
15.76 1.14
Table 20 shows that adolescent clients in this study were approximately twothirds male, one-third female, and reflecting similar ratios to previous WT study populations (Russell, 2003b, 2006b). Average age of participating adolescents was 15.8 (SD = 1.1) with 89 of the 115 participants being 15, 16 and 17 years of age, the youngest being 13, the oldest 18. No statistical differences were found between the clients from the two programs on age or gender characteristics. 135
Table 21. Substance use, mental health, and dual-diagnoses of clients entering wilderness therapy programs Diagnoses
Frequency
Percentage
Primary
Substance use Mental health Missing Total
35 79 1 115
30.4 68.7 0.9 100
Secondary
Substance use Mental health Missing Total
35 47 33 115
30.4 40.9 28.7 100
Yes No
40 75 115
34.8 65.2 100
Dual-diagnosed
Total
Clients enter WT programs with pre-assessed diagnoses or are diagnosed by criteria of the Diagnostic Statistical Manual for Mental Health Disorders 4th Ed. (DSMIV) (American Psychiatric Association, 1994) by program therapists. Primary and secondary diagnoses guide the formation of detailed treatment plans for therapeutic work with adolescent clients. Table 21 shows most clients (99.1%) entered treatment with a primary diagnosis or were given a diagnosis upon admission, and three quarters (71.3%) with a primary and secondary diagnosis. Additionally, one-third (34.8%) were found to be dual-diagnosed (i.e., concurrent disorders as defined by having both a substance use and mental health diagnosis) (see Castel, Rush, Urbanoski, & Toneatto, 2006). Dualdiagnosis increases the sophistication needed in treatment planning to address presenting and underlying behavioral and emotional issues. A second distinction will be made in analysis regarding client diagnosis. The sample will be divided by substance use only, mental health only, and dual-diagnoses to explore differences in outcome for these groups. 136
Response Biases Non-response bias between those adolescents and parents participating in the study, and those choosing to not participate, was not checked. Non-response bias between participants completing only pre-treatment or post-treatment measures (i.e., incomplete data sets) was compared with participants on both pre-treatment and posttreatment measures (i.e., complete data sets) using one sample t-tests. Additionally, response bias was examined using paired sample t-tests on all three measures—YOQ, BFAM, and WAI—to identify possible differences between mean adolescent and parent scores, and mean differences between programs. Response biases were considered significant at p = .05. Parent and adolescent overall response rates were quite similar for BFAM and WAI measures: 84-86% on pre-treatment BFAM, 51-54% on post-treatment BFAM, and 20-32% on pre-treatment and post-treatment WAI measures. Adolescent response rates on the YOQ dropped from 74% pre-treatment to 41% post-treatment and was mostly due to data collection errors at participating programs. Parent and adolescent mean BFAM scores were not found to be significantly different between complete and incomplete data sets, nor between the mean scores of the two programs. Adolescent mean YOQ scores were not found to be significantly different between complete and incomplete data sets, nor between the mean scores of the two programs. Parent WAI data collection resulted in six complete data sets and 51 incomplete data sets (single measures collected, pre: n = 27, post: n = 24) from 85 possible parent respondents, resulting in limited understanding of potential response bias on this measure. Mean pre-treatment to post-treatment differences in parent WAI scores were 137
not significantly different between the two programs, however, a near significant difference was found between complete and incomplete parent data sets (p = .056) on mean pre-treatment to post-treatment differences (complete data n = 6, x1 = 1.03; incomplete data n = 51, x2 = 14.83) although dubious to report due to highly irregular data. No significant differences were found for mean adolescent WAI scores pretreatment or post-treatment between complete and incomplete data sets, nor by program attended. Non-response analyses suggest limited bias between complete and incomplete data sets while not attending to potential biases between participants and non-participants of the study. Further, response biases were not found between programs, which supported the decision to aggregate quantitative data from both WT programs to maintain sample size and statistical strength in analysis for reporting total score results on each measure (Cohen, 1998). Of concern in interpreting these findings is the fact that program sample sizes are heavily unbalanced toward CFWT (i.e., approximately 85% of data analyzed). Further, the two-month post-treatment measure was unsuccessfully collected by programs, limiting analysis to only pre-treatment to post-treatment change, and subsequent “follow up” analysis. Family Function While programs identify a family systems approach in guiding treatment models, empirical evaluation of the effect of adolescent treatment on family function is limited in WT (Bandoroff & Scherer, 1994) and has only recently been revisited (e.g., Harper, Russell, Cooley & Cupples, 2007). The Brief Family Assessment Measure (BFAM, Skinner, Steinhauer & Santa-Barbara, 1983) was utilized to assess adolescent client and
138
parent perspectives of family function on self, dyadic and general scales pre-treatment and post-treatment. Tables 22 and 23 show parent and adolescent pre-treatment and post-treatment scores respectively for two BFAM scales: (a) self-rating, and (b) general scale. A third BFAM scale—dyadic—required each adolescent client and one designated parent to rate the level of function of their relationship. Data on this scale was not collected accurately, nor consistently enough, to be included in analysis. Further, only 14% of the BFAM parent measures and 20% of all BFAM adolescent measures were collected from AAA, with the majority of complete data sets collected at CFWT. Scores on each scale can total 42 (higher score depicts higher dysfunction); standardized t-scores and percentiles are calculated relative to family member completing the measure—adolescent, mother or father. The self-rating score reflects an individual’s perception of their functioning in the family, while the general scale is the respondent’s perception of how well the whole family is functioning (Skinner et al, 1983). Table 22. Scores from parent BFAM self-rating and general scales including pretreatment and post-treatment totals and results by program n
M pre
Mpost
Mdiff
t
p
d
35 35
13.74 16.29
13.20 15.17
.54 1.1
.852 1.41
.400 .167
.144 .240
5 5
13.0 15.2
12.0 15.2
1.0 0
.953 .000
.394 1.00
.426a 0a
Self 30 13.87 13.40 .467 .642 .526 General 30 16.47 15.17 1.3 1.58 .124 BFAM: Brief Family Assessment Measure a indicates a score lacking statistical strength (sample size < 10).
.117 .289
Total Self General Program Aspen Self General Freer
139
The average pre-treatment parent scores at admission for the self-rating scale were 13.74 (SD = 3.8), and 16.29 (SD = 4.7) for the general scale as seen in Table 23. Adolescent pre-treatment scores at admission were 20.96 (SD = 4.9) for the self-rating scale, and 21.78 (SD = 6.3) for the general scale. Pre-treatment scores on self-rating and general scales for family members provides a snapshot of how the family as a whole perceives its functioning and provides a baseline description for overall family functioning of this study population. Parent scores were in the 54th percentile for selfrating and 75th percentile for general family functioning pre-treatment. Adolescent scores were in the 79th and 82nd percentiles respectively. Table 23. Scores from adolescent BFAM self and general measures including pretreatment and post-treatment comparisons by participant and program variables n
M pre
M post
Mdiff
t
p
d
51 49
20.96 21.78
20.22 19.29
.745 2.49
1.09 2.79
.283 .008**
.152 .398
10 10
22.50 20.20
20.70 18.60
1.8 1.6
.762 .514
.465 .620
.240 .162
41 39
20.59 22.18
20.10 19.46
.488 2.72
.754 3.32
.455 .002**
.118 .531
31 30
20.10 20.60
19.23 16.83
.871 3.77
1.125 3.42
.270 .002**
.202 .624
20 19
22.30 23.63
21.75 23.16
.550 .474
.423 .331
.677 .744
.095 .076
17 16
21.76 23.69
20.65 21.13
1.12 2.56
1.59 2.37
.131 .031*
.387 .593
Total Self General Program Aspen Self General Freer Self General Gender Male Self General Female Self General Age 13-15 Self General 16
140
n
M pre
M post
Mdiff
t
p
d
Self 15 21.00 22.60 -1.6 -1.2 .250 -.309 General 15 21.73 21.13 .6 .354 .722 .094 17-18 Self 18 20.39 17.56 2.83 2.33 .033* .548 General 17 19.82 15.35 4.47 2.51 .023* .608 Length < 22 Self 13 19.31 20.15 -1.13 -.958 .357 -.266 General 11 19.91 20.55 -.375 -.744 .474 .057 22-47 Self 15 21.67 20.87 .909 .836 .009** .206 General 15 22.27 18.00 5.0 3.16 .050* .942b 48 + Self 23 21.43 19.83 2.53 1.25 .052 .572 General 23 22.35 19.52 4.13 1.79 .017* .567 Diagnosis Substance Self 8 21.38 18.00 3.38 2.37 .050* 1.26ab General 8 20.38 15.88 4.5 2.81 .026* 1.12ab Mental health Self 25 21.32 21.36 -.040 -.039 .969 -.008 General 23 22.65 20.74 1.913 1.19 .248 .267 Dualdiagnosis Self 18 20.28 19.61 .667 .601 .555 .138 General 18 21.28 18.94 2.33 2.09 .052 .360 BFAM: Brief Family Assessment Measure * indicates a score at post-treatment that is statistically different from the pre-treatment score at p < .05. ** indicates a score at post- treatment that is statistically different from the pre-treatment score at p < .01. a indicates a score lacking statistical strength (sample size < 10). b indicates a large to extra-large effect size as suggested by Cohen (1998).
The percentiles provide a direct comparison to normative data and represent, in this case, that 54-75 % of “normal” families have fewer family function problems than perceived by participating parents. Adolescent scores show higher problem perception on both self and general scales—they reported higher individual and family dysfunction 141
within the family than reported by parents. Parent pre-treatment to post-treatment differences in mean scores were insignificant, and improvement indicated by the parent BFAM general scale showed scores moving from the 75th to 66th percentile, suggesting that they still have more problems than 66% of the normative group. Adolescent BFAM scores improved from 79th to 74th percentile on the self scale, and from 82nd to 74th percentile on the general scales. Overall, aggregated adolescent BFAM scores were found to be improved, with pre-treatment to post-treatment BFAM general scale scores indicating statistically significant change (t(49) = 2.79, p < .01) with a medium effect size of d = 0.4. While statistically significant, adolescent BFAM general scale percentiles suggest that family functioning perceived by these clients is still 74% more problematic than the normative group. BFAM data were further analyzed by program, gender and age to more clearly understand where change had occurred. Analysis by program only revealed adolescent participants at CFWT reporting statistically significant (t(39) = 2.7, p < .01) improvements on the BFAM general scale. No significant differences were found between parent BFAM scales by program. Paired sample t-tests showed males reporting statistically significant differences in pre-treatment to post-treatment on the general scale (t(30) = 3.4, p < .01). While no statistical differences were found between gender, males reported lower scores on both scales pre-treatment and post-treatment compared to females (males- x1 = 20.5, x2 = 17.2, females- x1 = 24.2, x2 = 22.7). Participants were divided by approximate developmental stages (early, middle and late adolescence) to explore age differences more closely: (a) 13-15, (b) 16, and (c) 17-18 years of age. One-way analysis of variance showed 16 year-old participants 142
reporting significantly different change than younger and older groups (F(50, 2) = 3.95, p = .026) on BFAM self-rating scale, indicated by 16 year-old group scores that had deteriorated during treatment. Both 13-15 and 17-18 year-old group’s BFAM general scale scores improved significantly from pre-treatment to post-treatment (t(16) = 2.37, p < .05) and (t(17) = 2.51, p < .05) respectively, while 16 year-old scores only marginally improved. Significant improvements and medium effect sizes (d = 0.6) on self and general BFAM scales for 17-18 year-old participants indicated their perception of personal and overall improvements in family functioning between pre-treatment and posttreatment. Adolescent clients spending less than 22 days in WT did not report significant change on either BFAM scales, while both the 23-47 and the 48+ day client groups showed statistical significance on BFAM general scales from pre-treatment to posttreatment (t(15) = 3.16, p < .05) and (t(23) = 1.79, p < .05) respectively. Additionally, these two longer program length groups showed statistical or near statistical improvements on the BFAM self scales (t(15) = 0.84, p < .01) and (t(23) = 1.25, p < .05) respectively. One-way analysis of variance showed no significant differences between treatment length group outcomes on the BFAM self and general scales (F(2, 48) = .1, p = .36) and (F(2, 46) = 2.1, p = .13) respectively. Diagnoses were grouped by substance use only, mental health only and dual-diagnosed (i.e., having both substance and mental health diagnoses). While only a small sample (n = 8), the substance use only diagnosis group reported statistically significant pre-treatment to post-treatment change on BFAM self and general scales (t(8) = 2.37, p < .05) and (t(8) = 2.81, p < .05) respectively. Additionally, the dual-diagnosed group reported near significant results on 143
the BFAM general scale (t(18) = .60, p = .052). One-way analysis of variance showed no significant differences in scores between diagnoses groups on the BFAM self or general scales (F(1, 49) = .01, p = .93) and (F(1, 47) = .17, p = .9) respectively. Adolescent Outcomes Previous studies of this WT population have indicated positive outcomes for adolescents based on the social, emotional and behavioral scales of the Youth Outcomes Questionnaire (YOQ, Burlingame et al., 1995; Russell, 2003b). To place this study within the context of the long-term program of research conducted by OBHRC, it was necessary to evaluate changes experienced by adolescents with similar measures for comparison purposes. Additionally, adolescent outcomes provide an opportunity to compare change in client with change in client’s family system. This study assessed adolescent outcomes with the YOQ 30SR which is a condensed version of the YOQ 30.1 previously used in OBH studies (see Russell, 2003b). A Reasonable Change Index (RCI) has been established by the YOQ 30SR authors to indicate clinical significance and will be reported along with statistical significance and effect sizes (i.e., Cohen’s d). Total score measures overall severity of individual ‘disturbances’ including emotional distress, social and behavioral problems. A clinical level of change is indicated by a difference in pre-treatment to post-treatment score of ten points. Total scores above 30 indicate that the individual is in a clinical range, while scores below 30 are non-clinical or normal. Higher scores equal higher dysfunction. Table 24 shows the average scores for adolescents by program, gender, age, treatment length and diagnosis. Again, it is noteworthy that the majority (90.5%) of complete data sets in the YOQ analysis were collected at CFWT. 144
Table 24. Scores on adolescent YOQ including pre-treatment and post-treatment comparisons by program, gender, age, treatment length group and diagnosis group variables n
M pre
M post
Mdiff RCI
t
p
d
Total 42 38.57 31.07 7.50 2.62 .012* .402 Program Aspen 4 46.50 28.00 18.50 1.59 .211 .794a Freer 38 37.74 31.39 6.34 2.17 .036* .352 Gender Male 15 46.93 31.27 15.67 3.03 .009** .783 Female 27 33.93 30.96 2.96 .939 .356 .182 Age 13-15 14 48.14 36.50 11.64 1.97 .070 .527 16 15 38.47 32.07 6.40 1.87 .083 .460 17-18 12 28.08 25.25 2.83 .480 .641 .138 Length < 22 14 38.43 34.07 4.36 1.05 .315 .250 22-47 12 36.17 29.58 6.58 1.11 .292 .381 48 + 16 40.50 29.56 10.94 2.19 .045* .622 Diagnosis Substance 6 32.00 28.83 3.17 .589 .581 .269a Mental 20 39.55 36.95 2.6 .595 .559 .162 Health Dual 16 39.81 24.56 15.25 3.53 .003** .802b diagnosis YOQ: Youth Outcome Questionnaire 30SR * indicates a score at post-treatment that is statistically different from the pre- treatment score at p < .05. ** indicates a score at post- treatment that is statistically different from the pre- treatment score at p < .01. a indicates a score lacking statistical strength (sample size < 10). b indicates a large to extra-large effect size as suggested by Cohen (1998).
Overall, total YOQ scores show an RCI of 7.50 and a statistically significant difference of mean scores from pre-treatment to post-treatment (t(42) = 2.62, p < .05), but were not indicated as clinically significant by RCI. Total scores at pre-treatment were in the “clinical” range (i.e., >30) and comparable to outpatient and day treatment populations as described by the authors (Burlingame et a., 1995). Further, score 145
reductions post-treatment neared the “non-clinical” or normal range cut-off score of 30. By program, AAA participants (cautiously reported, n = 4) scores produced an RCI of 18.50 and CFWT an RCI of 6.34. Males showed clinically significant RCI score improvement with a mean difference of 15.67, while females showed an RCI of 2.96. Additionally, male YOQ scores were statistically different between pre-treatment and post-treatment (t(15) = 3.03, p < .01). The 13-15 year-old age group showed significant clinical improvement between pre-treatment and post-treatment scores with an RCI of 11.64, a medium effect size of d = 0.5, and approached statistical significance (t(14) = 1.97, p = .07). The 17-18 year-old group showed the least amount of change with an RCI of only 2.83. One-way analysis of variance on difference of scores showed no statistical difference between age groups on YOQ outcomes (F(2, 38) = .73, p = .49). Treatment length produced YOQ outcomes consistent with earlier WT research (Russell, 2003b) in that the 48+ day group showed clinical and statistically significant change RCI = 10.9, (t(16) = 2.19, p = .05) while shorter treatment lengths were not found to be statistically different. One-way analysis of variance showed no statistical differences between groups on treatment length (F(2, 39) = .48, p = .63). Diagnoses groups of (a) substance use only, (b) mental health only, and (c) dual-diagnoses produced clinically relevant differences between groups (RCI of +/- 10 pts.). While one-way analysis of variance showed no statistical difference between diagnoses groups (F (2, 39) = .24, p = .1), the dual-diagnosis group showed statistical significance between pretreatment and post-treatment scores (t(16) = 3.53, p < .01), an RCI of 15.3 and the largest reported effect size for the YOQ measure (d = 0.8). This result was more than 10
146
points higher than either the substance use only, or mental health only groups (substance, RCI 3.17, mental health, RCI 2.6; dual, RCI 15.25). Working Alliance An effective and meaningful relationship between client and therapist—the working alliance—has been suggested to be the strongest in-treatment predictor of outcomes (Horvath, 2001). The strength of the working alliance was assessed in adolescent-therapist and primary parent-therapist relationships to illuminate change in this relationship and how it may relate to outcomes. Measures were not collected at pretreatment, but rather within the first week of treatment, as it was reasoned that participants would (a) not have any grounds to judge a relationship pre-treatment, and (b) adolescents may be very resistant to participating as they are often admitted against their will and would need a few days to adjust to WT and working with the clinical team. It is important to note here that the alliance measure was completed by adolescents in one WT program with the option of choosing any member of the clinical team, while the other program directed adolescents to complete the alliance measure considering only the relationship with their therapist. Data collection did not however, provide enough clarity to distinguish which adolescent measures were completed based on field staff or therapist relationships with adolescent client. Therefore, data analysis and further discussion consider the alliance as the relationship between each adolescent participant and a therapist/leader, a chosen member of the “treatment team.” Additionally, all complete data sets were collected from CFWT and prevent any analysis by program and presents complete bias in reporting toward one program. Finally, WAI results are presented with the early measure described as “pre-treatment” for reporting continuity. 147
Table 25 shows parent and adolescent pre-treatment and post-treatment scores on the Working Alliance Inventory (WAI, Horvath & Greenburg, 1989). Overall adolescent scores showed a significant difference between pre-treatment and post-treatment (t(31) = 2.99, p < .01) and a medium effect size of 0.54. While male and female WAI scores increased, only male scores showed significant improvement from pre-treatment to posttreatment (t(19) = 2.22, p < .01). Younger participants (13-15) showed only marginal increases on WAI scores while 16 and 17-18 year-old age groups showed significant improvement pre-treatment to post-treatment (t(9) = 3.31, p < .01) and (t(8) = 2.58, p < .05) respectively. With the exception of 13-15 year-old participant results, all results showed medium to large effect sizes (d = 0.51 to 1.11). One-way analysis of variance showed no statistical differences for pre-treatment to post-treatment scores between age groups (F(2, 27) = 1.1, p = .36). Table 25. Scores on adolescent and parent WAI including pre-treatment and posttreatment by program, gender, age group, treatment length group and diagnosis group variables
Adolescent Total Program Aspen Freer Gender Male Female Age 13-15 16 17-18 Length < 22 22-47
n
M pre
M post
Mdiff
t
p
d
31
44.81
49.23
4.42
2.99
.005**
.538
0 31
44.81
49.23
4.42
2.99
.005**
.538
19 12
44.26 45.67
48.53 50.33
4.26 4.67
2.22 1.94
.040* .078
.508 .561
13 9 8
45.62 42.56 46.63
47.92 50.11 50.63
2.03 7.56 4.00
.780 3.31 2.58
.450 .011** .036*
.190 1.11ab .914ab
10 10
46.80 41.30
49.70 45.70
2.9 4.40
2.0 1.33
.076 .217
.417 .049 148
n
M pre
M post
Mdiff
t
p
d
48 + 11 46.18 52.00 5.28 2.15 .057 .726 Diagnosis Substance 5 45.00 53.20 8.2 1.8 .142 1.42ab Mental 13 46.62 50.77 4.15 2.31 .039* .50 Health Dual 13 42.92 46.15 3.23 1.23 .232 .388 Parent Total 6 39.33 54.17 14.83 2.67 .044* 1.09ab WAI: Working Alliance Inventory * indicates a score at post-treatment that is statistically different from the pre- treatment score at p < .05. ** indicates a score at post- treatment that is statistically different from the pre- treatment score at p < .01. a indicates a score lacking statistical strength (sample size < 10). b indicates a large to extra-large effect size as suggested by Cohen (1998). No statistical differences were found on WAI pre-treatment to post-treatment scores by treatment length although the 48+ day group presented near significant results (t(11) = 2.15, p = .057). One-way analysis of variance showed no statistical differences between treatment length groups (F (2, 28) = .32, p = .73). Diagnoses group analyses found statistical pre-treatment to post-treatment differences for the mental health diagnosis group only (t(13) = 2.31, p < .05) while substance only and dual-diagnosed groups, while showing improvement, were no statistically significant. One-way analysis of variance showed no statistical differences between diagnosis groups (F (2, 28) = .66, p = .53). While parent WAI scores showed significant improvement from pre-treatment to post-treatment (t(6) = 2.67, p < .05), completion of measures was inconsistent and resulted in six complete data sets lessening statistical strength. Numerous WAI parent measures had written feedback on them reflecting an incongruence between questions asked and the nature of their perceived relationship with program therapists. Parents 149
written remarks on completed WAI measures included statements clearly indicating that they did not see themselves as being in a therapeutic relationship with the WT therapist, and further, that the measure was appropriate for their children, but not for them. Parents with this type of feedback on completed pre-treatment measures tended to score higher WAI levels on post-treatment measures and did not provide further written commentary. Correlations Relationships are explored between adolescent’s perception of (a) individual social/psychological change, (b) individual change in family function, (c) general change in their family system, and (d) therapeutic working alliance experienced with their WT therapist. These relationships are analyzed to better understand adolescent perception of change, how that change manifests in the family, change in the overall family function, and what role the working relationship with WT clinical team played in effecting these outcomes. Correlation coefficients were computed including the pre-treatment to posttreatment differences in scores on the YOQ and self and general scales of the BFAM and the WAI. The Bonferroni approach was utilized to control for Type I error across the 8 correlations. P values of .006 (.05 / 8 = .006) were required to report significance. Table 26. Correlations of pre-treatment to post-treatment score differences on adolescent YOQ, self and general scales of BFAM and WAI Diff pre-post Diff pre-post Self YOQ BFAM .31 Diff in Self BFAM .24 .61* Diff in Gen BFAM .11 .04 Diff in WAI * indicates statistically significant correlation at p < .006
Diff pre-post Gen BFAM
-.17
150
Table 26 presents correlations between pre-treatment to post-treatment differences of scores on adolescent YOQ, BFAM self and general scales, and WAI. Only the relationship between adolescent self and general scales were found to be significant (r = .61, p < .006) following Bonferroni correction for Type I error. This moderately strong correlation represents the relationship of adolescent perception of individual change and perception of overall improvements in family functioning. All other correlations were weak to very weak, showing no relationship between values. Multiple Regressions: Variables Predicting Outcome Participant-level and program-level variables of age, gender, diagnosis, treatment length and change in WAI were presumed to have explanatory power and utilized to further understand outcomes. These variables were analyzed in combinations representing (a) pre-treatment demographics of age and gender combined as objective variables brought to the treatment setting, and (b) assessment, diagnosis established by therapists and treatment length and mean difference in working alliance as program factors varying from client to client. These two predictor models were run in two sets of multiple regression analyses to predict pre-treatment to post-treatment change on the (a) BFAM self, and then (b) YOQ scales. Regression analysis of the BFAM general scale was reasoned to not offer any further meaningful understanding of the family system as suggested by Cook’s (2005) critique of the scale’s inability to recognize independence of family members. The first regression equation including client demographics of age and gender as predictors for the BFAM self scale was not significant, (R2 = .009, adjusted R2 = -.033, F(2, 47) = .217, p < .05). The second regression equation including diagnosis, treatment 151
length and WAI difference as predictors for the BFAM self was also not significant (R2 = .117, adjusted R2 = .007, F(3, 24) = 1.06, p < .05). Based on these results, neither pretreatment variables of client demographics, nor in-treatment variables are significant predictors of outcome of client’s change reported on the BFAM self scale. The YOQ was then analyzed with the two regression equations previously listed. The first regression equation including client demographics of age and gender as predictors for the YOQ was significant (R2 = .149, adjusted R2 = .104, F(2, 38) = 3.33, p < .05). The second regression equation including diagnosis, treatment length and WAI difference as predictors for the YOQ was not significant (R2 = .067, adjusted R2 = -.081, F(3, 19) = .453, p < .05). These results suggest that demographics of age and gender provide predictive power for YOQ outcomes, while in-treatment variables of diagnosis, treatment length and working alliance do not. In relationship to paired sample t-tests previously reported, it appears that younger males tend to show greater improvements on YOQ scores. An additional regression equation was constructed to assess the relative strength of all participant-level and program-level variables in predicting YOQ outcomes. The linear combination of all predictor variables was not significant (F(5,16), .681, p < .05). The correlation co-efficient was R = .42, adjusted R2 = .176 indicating approximately 18% of variance in YOQ scores can be explained through the linear combination of these predictor variables. Table 27 shows relative strengths of individual predictor variables of YOQ outcomes. No individual predictor was found to be significant in this analysis (p < .05) and age was found to be negatively correlated suggesting again that younger WT clients are reporting greater outcomes than older participants. 152
Table 27. Bivariate and partial correlations of predictor variables for YOQ outcomes and percentage of variance explained Predictors
Correlations between predictors and YOQ
-.310 Age .322 Gender .146 Diagnosis .170 Treatment length .091 WAI difference YOQ: Youth Outcome Questionnaire WAI: Working Alliance Inventory
Correlations between predictors and YOQ controlling for other predictors -.150 .203 .185 .096 .093
Percentage of YOQ variance explained by predictor 5.5 5.6 2.6 3.0 1.5
Variance explained totaled 17.6% and was primarily shown to be predicted by age (5.5%) and gender (5.6%) while the remaining three predictors combined explained the remaining 6%. Due to being correlated, these findings do not have causal explanatory power, but do suggest interesting results for WT practitioners. Further, with more than 80% of variance unexplained, a need exists to explore other realms of the WT treatment milieu as influencing outcome. Summary of Quantitative Results This section serves as a brief synopsis of the quantitative results. While analysis provided an overall picture of family and adolescent outcomes, most complete data sets were collected from CFWT and limit generalizations to AAA and other WT programs. Short descriptions of outcomes for each measure are shared and are further discussed in Chapter Five. Regarding family functioning, BFAM analysis with the total sample produced significant results for the self-rating and general scales with effect sizes of d = 0.2 and d 153
= 0.4 respectively. Analysis across client and program variables showed the general scale more often producing significant results than the self-rating scale. The general scale produced significant improvements for males, 13-15 and 17-18 year-olds, but not for females or 16 year-olds. Treatment lengths of greater than 22 days produced significant results on the general scale while shorter programs did not, while the 22-47 day group also showed significant differences on the self-rating scale. The substance use diagnoses group produced significant results on both BFAM scales while no significant results were found for mental health and dual-diagnosed groups. Parents completing the BFAM reported a general trend of non-significant improvement on both scales. An overall trend of increased adolescent BFAM scores were found except for 16 year-olds on the self-rating scale, the
