Wilderness Therapy and Adolescent Mental Health - Springer Link

Administration and Policy in Mental Health Vol. 18, No. 5, May 1991

WILDERNESS THERAPYAND ADOLESCENT MENTAL HEALTH: ADMINISTRATIVEAND CLINICAL ISSUES Dene S. Berman, Ph.D. and Jennifer Davis-Berman, Ph.D.

1985). This data strongly suggests that the vast majority of adolescents in need, perhaps 70-80%, are not receiving mental health treatment (Tuma, 1989). Given this lack of treatment, it is critical to re-evaluate the methods used to intervene with adolescents. In traditional agency setings (i.e., public or private mental health centers, clinics, hospitals, residential treatment centers), programs are developed which utilize existing treatment approaches (e.g., behavioral or psychodynamic therapy), modalities (individual, family or group therapy), and settings (inpatient, residential or outpatient settings). Using such traditional components in program planning may serve to severely restrict the range and character of therapeutic activity that is possible. For example, adolescents in outpatient treatment are usually seen in the office setting, for a specified amount of time, and are exposed to verbal/cognitive methods of behavior change (Hobbs & Shelton, 1972). Another example is how, in a hospital setting where one's mobility is limited, passivity may be a desirable concomitant to milieu therapy (Weisman, M a n n , & Baker, 1966). Clearly, these examples illustrate the rela-

Adolescence, in general, is often characterized as a period of storm and stress (Blos, 1962; Erickson, 1968) in which intra- and interpersonal conflicts are common. Obviously, much of the difficulty of this time is considered "normal," and intervention is not required. However, epidemiological studies suggest that 15-20% of adolescents have treatable mental health problems that go beyond this normative developmental turmoil (Tuma, 1989). Despite this significant need for mental health service in this particular age group, the gap between need and service utilization is quite large. In support of this contention, a recent N I M H study reported that only 3.2 % of children under the age of 18 are seen in outpatient mental health centers (Tuma, 1989). Additionally, fewer than 1% of children and adolescents are treated in inpatient psychiatric facilities (Taube & Barrett,

Dene S. Berman, Ph.D., is affiliated with Lifespan Counseling Associates, and Wright State Univ., Dayton, OH. Jennifer Davis-Berman, Ph.D., is affiliated with the Department of Social Work, University of Dayton, Dayton, OH, 45469 and Lifespan Counseling Associates. 373

9 1991 Human Sciences Press, Inc.

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tionship between traditional planning and the development of conventional service systems. It can be suggested that the nature of these services discourages the adolescent client from seeking help, and that these types of programs do not represent opportunities for optimal change in adolescents. Traditionally, the planning process has been discussed within the context of "planning models," such as the organismic, communalistic, and individualistic approaches (Gilbert & Specht, 1986). Although these planning strategies may certainly lead to the development of public and private mental health services, the adaptability and innovativeness of such programs can be questioned. When planning programs for adults, these strategies may be adequate, as innovation and creativity may not be necessary. When dealing with adolescents, however, greater creativity may be essential. Quite possibly, the low rates of service utilization by troubled adolescents could be increased by adopting a more innovative approach to program planning. It is the contention of the present article that a systems approach to program planning offers a perspective which allows and even encourages the development of creative programming for adolescents. As such, this article provides a short background on systems theory, and then presents the Wilderness Therapy Program as a treatment program for adolescents which represents a system approach to service delivery.

SYSTEMSTHEORY Systems theory as a scientific paradigm is fairly recent in its development. Its earliest roots were in the biological sciences (Von Bertalanffy, 1950), with applications of the perspective being made to the social sciences a few years later (Miller, 1955; 1965). More recent work in the social sciences has led to the development of refined definitions of systems terms and implications for program planning and practice. In this context, a system may be regarded as a "whole, a unit, composed of people and

their interactions, including their relationships" (Compton & Galaway, 1989, p. 124). Thus, the individual adolescent can be seen as a system. Importantly, all healthy open systems contain smaller subsystems, and also are contained within a larger suprasystem. Thus, the individual system exists between the suprasystems and the subsystems (Compton & Galaway, 1989). By adopting a systems perspective from the beginning of the planning process, one moves toward a more flexible definition of the presenting problem. Various systems can be identified, such as the family system, as being problematic, rather than simply identifying the adolescent as the problem. This contention is supported by systems theory which asserts that systems are constantly interacting, and that a change in one system serves to affect all other systems (Kaplan, 1986). Finally, one of the cornerstones of systems theory is its focus on the mutual transactions between systems and their environments (Compton & Galaway, 1989). This has been written about using various terminology. Examples include: the "relation between the coping activity of people and the demand from the environment" (Bartlett, 1970, p. 116); and a "simultaneous dual focus on individuals and the environment" (Gordon, 1969, p. 6). Clearly, this model leads one towards a person/environment perspective in designing programs and working with clients (c.f., Germain & Gitterman, 1980; Siporin, 1975). The Wilderness Therapy Program represents an example of a program developed within a systems theory framework. With this approach, adolescents are not blamed or judged, but rather, the entire family and other subsystems are considered in problem definition. Additionally, and most importantly, the person/environment perspective forms the core of this program where optimal, rapid change can occur. In an attempt to illustrate this systems approach to program planning, the remainder of this article will present the Wilderness Therapy Program as an example. Following Marshall (1930), we will refer to Wilderness

Dene S. Berman and Jennifer Davis-Berman

as, "a region which contains no permanent inhabitants, possesses no possibility of convergence by any mechanical means, and is sufficiently spacious that a person crossing it must sleep out" (p. 14). In using the term therapy, we refer to a planned course of intervention, with objective treatment goals for each participant. Each of these individuals is referred by a mental health professional, and has symptoms consistent with a D S M - I I I diagnosis. Finally, within the definitional boundaries of Wilderness Therapy, many possibilities exist. However, the essential components involve taking troubled youth into uninhabited areas for more than a few days. The group sleeps out overnight, and is self-sufficient. The primary goal of the program is to create change in the previously identified problem areas for each participant.

PROGRAM PLANNING Rationale. The first step in planning a wilderness program involves the determination of the niche that it fills within the larger agency suprastructure. In other words, how would a wilderness program mesh with agency goals and currently offered programs? Examples of goals that are consistent with wilderness counseling include: 1. Service delivery systems for adolescents should encompass a range of settings. 2. Services should be provided in the least restrictive environment. 3. Counseling services for adolescents should be flexible and not necessarily constrained by office walls. 4. Some adolescents are in need of situations in which consequences for behavior are immediate, naturally occurring or contingent on one's behavior. If these goals are not considered within such a systems perspective, the program may conflict with more traditional programs in terms of staff allotment, budgetary consid-

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erations, treatment planning and a host of other considerations.

Participants. Early in the planning process, decisions must be made about who will participate in wilderness counseling. Participants include both staff and adolescents. Unlike traditional programs, the participants become a very critical subsystem themselves, often having a great impact on the success or failure of the program. At a minimum, staff should be comfortable with their own wilderness skills so that they can focus on the needs of the adolescents instead of struggling with their own issues. They should also be prepared to respond in an emergency. First aid and C P R certification may be staff prerequisites. O f course, there will need to be some training for psychiatric emergencies; for example, how to handle a participant who has a break with reality and tries to run away. The constellation of staff qualifications will depend on the needs of the adolescents and the type of setting sponsoring the program. More troubled adolescents will require a higher staff to patient ratio and more highly trained staff. A hospital setting may require that a physician participate directly in trips or supervise them closely. Having participants who are on medication or who have physical problems that require medical management may require the presence of medical staff. Otherwise, having at least one therapist who coordinates wilderness counseling and is independently licensed or certified may suffice. While it may be desirable to have staff participate who are as comfortable in the wilds as they are in the clinic, staffwith these qualifications are indeed rare and may not be needed. Instead, one can opt for having a staff position for someone who will coordinate the physical aspects of the trip, including training of staff and adolescents, determining trails, camp sites, water and food needs, evacuation routes and coordinating an itinerary with the proper wilderness authorities. Organizations like the Wilderness Education Association certify individuals who qualify as outdoor leaders and provide a job referral service for locating leaders. It is recommended that trips be planned with one population only. Our experience has found that wilderness counseling is most effective for participants who are withdrawn

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and have difficulty sharing and being close to others as well as more acting-out adolescents who can benefit from an environment in which cooperation is rewarded with natural, immediate consequences. This type of subject selection illustrates our systems based focus on individuals and their environments. O u r goal has been to accept only those participants who have the cognitive ability to incorporate their wilderness experiences into a framework that will enhance their ability to make changes when they return home. Thus, we have excluded individuals with limited cognitive ability, severe Attention Deficit Hyperactivity Disorder with (ADHD) and active psychosis. We have also elected to exclude individuals who pose a physical threat to harm themselves or others. Finally, we exclude individuals with medical needs that would put them at risk.

Treatment Planning.

Treatment planning is a critical part of the planning process for wilderness therapy. As therapy, specific behaviors should be targeted for change and the method for achieving these changes should be specifiable. In the same way that agency clients receiving more traditional services have individual treatment plans, so should wilderness participants. The nature of the Wilderness Therapy Program enables participants to reap certain benefits that accrue as a result of participation. Cooperation, taking responsibility for one's self and possessions, and effective communication with others are reinforced for all participants. A variety of other behaviors are amenable to change in this setting, including but not limited to getting along with authority figures, increasing one's activity level and other symptoms related to depression, and learning to express anger in acceptable ways.

Physical Aspects. Points to be considered include the following: the length of the trip, trip location (including maps and trail selection), transportation, staff-to-participant ratio, equipment needs, menu and medical needs (including a first aid kit and emergency procedures). In our experience, this aspect of planning takes months to complete. The trail should be familiar to key staff and an itinerary

should be filed with the proper officials (e. g., park or forest rangers). The location of potable water, camping sites and evacuation routes should be noted. The trail conditions, time of year and anticipated weather conditions will all affect food and equipment needs. O f course, an alternative to this phase of planning is to retain the services of others who can provide these services. A guide (hopefully, one sensitive to mental health needs) may be found by contacting a local camping store, a university that offers backpacking courses or organizations that train outdoor leaders like the Wilderness Education Associaton.

PROGRAMIMPLEMENTATION The Trip. If participants have not been trained in essential camping skills before the trip, instruction can occur in basecamp. Participants seem most receptive to this training when it combines didactic and experiential learning with an opportunity to use the skills once they are acquired. For example, teaching the use of the stoves can be taught just before dinner time, when they will be used. We have conducted group therapy on at least a daily basis and that the time immediately following lunch is best. Holding sessions in the morning may mean that camp is not broken until after lunch and holding sessions after dinner may mean that everyone is tOO tired to actively participate. O u r sessions have tended to focus on the participants' current experiences and then to tie them in with treatment goals, past history or future plans. O r they can be used to build trust and cohesiveness through exercises like the "trust walk." Sometimes it is useful to have more than one session per day, especially to resolve conflicts. If one views a group session as the most appropriate place to process conflicts (using the metaphor of the group as a family), then anyone can ask for the group to convene in order to resolve conflicts. As soon as a session is concluded the participants write in their journals while staff record progress notes. T i m e is always devoted to studying the surroundings. Trees, vegetation, wildlife,


and geology are discussed as observations are m a d e - - a n d the participants are encouraged to share their own knowledge, either gained before the trip or with the help of various field guides brought on the trail. The history of the area is also an important topic that is usually discussed in basecamp, often with the help of the rangers.

Post Trip. Plans should be made before the trip to facilitate the generalization of gains once the participant returns home. Parents, school personnel and others do not anticipate large gains to be made by the participant and, if unprepared, may make it difficult for gains to be maintained. For this reason, parents and others should be prepared for the participants' return. Similarly, it is important for the participants to be prepared for their return to "civilization." In an attempt to determine long term effects of the Wilderness Therapy Program, questionnaires and standardized instruments are periodically sent to participants to formally evaluate their post-trip progress. We are now completing the collection of two year follow-up data for participants of four outpatient trips.

EVALUATION Evaluation of a wilderness program is a multifaceted endeavor. Certainly, one must consider positive change on the part of the participants, one element of which is change in individual treatment goals as documented in daily progress notes kept on the trail and after the trip. Participant change can also be assessed in other ways such as through standardized, objective tests to measure preposttest change, or even through use of control groups in an experimental design. Subjective changes can also be measured by following participants' daily records of their thoughts and feelings in their journals and the behavioral changes noted by staff and clients while on the trail. The evaluation process can also involve examination of the agency and its goals, akin to traditional program evaluation research.

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This evaluation could focus on both the process and outcomes of the program, as well as a cost/benefit analysis (Suchman, 1967). Other agency evaluation concerns might be on publicity or potential increases in referrals. Finally, wilderness programs should also be evaluated in terms of more widespread, systems factors. It has been our experience that agency staff participation in wilderness programs boosts morale and a feeling of espirit de corps. Parents, too, may feel that the agency has addressed some of their concerns about positive influences on adolescents' value systems. If community institutions, like the newspaper, radio, granting agencies, public service organizations and the like are involved with a wilderness program, the agency becomes more a part of the community in which it operates.

ADMINISTRATIVE ISSUES Marketing. Due to the innovative nature of the Wilderness Therapy Program, marketing is a key administrative issue. First and foremost, the agency staff must be involved in the planning of the program and must support it. Thus, if needed, time should be spent "marketing" this program with the staff. We have found overwhelming support for this program among those working with adolescents. However, the public must be made aware of the program before this support can be demonstrated. This marketing plan can facilitate the appropriate referral of adolescents to the program, and may also help garner community support for the program and the agency. Some marketing ideas include: placement of brochures in libraries and other public facilities, and mailings to local mental health professionals. The media can also be used effectively as a marketing tool. Financial Considerations. The cost of developing and implementing a wilderness program can be excessive. These costs are obviously much higher during the initial

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trips, and tend to even out as the program becomes more established. For example, the first trips involve purchasing all of the necessary camping equipment. Subsequent trips will use the same equipment, however, food will need to be purchased, transportation costs may be high, and staff salaries must be included. However, the benefits of this kind of program greatly outweigh the high costs. In fact, there are ways to defray these costs, and make wilderness treatment more fiscally attractive. First, insurance companies will reimburse therapeutic programs like these if they are part of the client's treatment plan, and if services are provided by psychiatrists, psychologists, or social workers. Care must be taken, however, to develop treatment plans and document the provision of therapeutic services. Networking with local agencies may also help defray costs. Camping stores may be of help in providing discounts or leasing equipment. Service organizations, like the Jaycees, are invaluable in providing scholarships for deserving adolescents. Finally, grants may be available from a variety of federal, state, or local agencies. Innovative program development for adolescents is high on the federal priority list for funding.

CONCLUSIONS The Wilderness Therapy Program encourages a systems definition of problems, and focuses on the power of the challenging natural environment in effecting change in adolescents. Although there are difficulties with planning and implementing this type of program, its benefits go far beyond the negative aspects. It is hoped that these programs will benefit not only the participants, but the agencies as well. Not only is systems theory applicable when one considers the relationship between wilderness programs and more traditional programs, it is also relevant to the relationship between the agency and the community from the aspect of marketing and funding

issues. Furthermore, preparing staff, parents and significant others of wilderness participants to foster and maintain changes made on the trail is certainly consistent with a systems theory perspective. With competition for agency funds at an intense level, agencies that respond in creative ways will distinguish themselves as leaders in the community. By developing innovative programs like the wilderness program, public visibility and referrals to the agency will increase. It is through such a systems-oriented program that benefit to all--the adolescent, the family, the community, and the agency--is fully realized.

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