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Journal of Contemporary Psychotherapy Vol. 19, No. 4, Winter 1989

The Wilderness Therapy Program: An Empirical Study of Its Effects with Adolescents in an Outpatient Setting JENNIFER DAVIS-BERMAN, PH.D. AND DENE S. BERMAN, PH.D.

ABSTRACT: The results of a study of the Wilderness Therapy Program involving 23 adolescents in outpatient counseling are presented. Data were collected before and after four trips on measures of locus of control, behavioral symptoms, self-efficacy, self-esteem, and a number of measures designed specifically for this program. Following a one and one-half to two week backpacking trip that included daily therapy, significant change was found for locus of control, self-esteem and symptom reduction. Positive changes were noted on the other measures as well. Future directions and social work implications were discussed. INTRODUCTION u t d o o r t r e a t m e n t a p p r o a c h e s with adolescents have long b e e n r e c o g n i z e d as effective alternatives to traditional therap e u t i c intervention. Early r e p o r t s w e r e n o t b a s e d empirical studies o f o u t d o o r p r o g r a m s , b u t rather, p r e s e n t e d clinical impressions o f effectiveness. F o r e x a m p l e , an e d i t e d v o l u m e by L o w r y (1974) p r o v i d e d a n e c d o t a l r e p o r t s on a n u m b e r o f "camping t h e r a p y " p r o g r a m s , s p a n n i n g the largest p a r t o f this century. A l t h o u g h interesting in their p r e s e n t a t i o n , t h e majority o f these p r o g r a m s s e r v e d an ill-defined g r o u p o f psychiatric patients, m a k i n g generalizations to o t h e r p a t i e n t g r o u p s difficult. Addi-

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Requests for reprints should be sent to Jennifer Davis-Berman, Ph.D., Department of Social Work, University of Dayton, Dayton, OH 45469. 271

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tionally, although seemingly effective, these reports offered little objective data on which to evaluate the actual efficacy of the programs. Thus, the early writings on outdoor treatment programs, subjective in nature, contributed little to the evaluation of innovative practice techniques. In much the same way, the literature on popular programs, like Outward Bound, supports the effectiveness and value of wilderness approaches to therapy. This literature suggests that personal growth and change does occur (cf., Godfrey, 1977), and that these changes are most significant in the areas of: self esteem, self-awareness, self-assertion, and acceptance of others (Burton, 1981; Hendy, 1975). However, published reports on these programs are largely anecdotal, are generally geared toward well functioning youth, do not involve group or individual therapy and are replete with design problems.

REVIEW OF THE LITERATURE In an attempt to increase the rigor of the evaluations of outdoor programs, some investigators have applied more stringent scientific criteria to their work. Thus, there is a growing body of literature which attempts to evaluate these types of programs. Generally, this literature tends to focus on outdoor programs as mental health treatment, and appears to be divided between inpatient and outpatient programs.

Inpatient Programs Adams (1970) evaluated a 30-day wilderness program for 19 adolescent psychiatric inpatients, with non-hospitalized adolescents serving as a comparison group. Follow-up data up to 28 months after the trip suggested that the inpatients experienced increases in self esteem, self reliance, and feelings of physical adequacy, and that their rehospitalization rate at follow-up was only 15%. Although promising, these results must be interpreted tentatively, as baseline rehospitalization rates were not included. Positive change in psychiatric patients was also demonstrated by Jerstad and Selzer (1973). Thirty-one out of the total fifty-one program participants experienced improvements on the trip suf-

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ficient to warrant their discharge from the hospital following the wilderness program. Once again, although encouraging, these results are fraught with problems such as the reliance on clinical impressions of improvement rather than on objective data, the lack of a comparison group, and finally, the ages of the participants in this program ranged from adolescents to the elderly. In presenting the results, no breakdown of the differential effects of the treatment on specific age groups was presented. Thus, it was impossible to draw conclusions regarding the efficacy of this program for adolescents. Finally, Berman and Anton (1988) reported on two wilderness therapy trips with 14 adolescents from the inpatient units of two psychiatric hospitals. A number of outcome measures were employed, including the Rotter Locus of Control Scale (Rotter, 1966), a measure critical incidents on the trips, and the Brief Symptom Inventory (BSI) (Derogatis, 1975). Participants became more internal in their locus of control following the trip, and appropriate decreases in symptoms were found (Berman & Anton, 1988). While these studies, too, have methodological difficulties, they clearly suggest that outdoor approaches to therapy with institutionalized adolescents may be quite effective.

Outpatient Programs These methodological problems also extend to the literature which evaluates the effectiveness of wilderness programs as treatment for community residing adolescents. Kaplan (1974) evaluated the impact of an outdoor program on the self-esteem and self-evaluation of 10 male adolescents. A matched group of high school students served as a comparison group. Six months after the program, participants had maintained increased selfesteem, more realistic self-evaluation, and greater concern for others. This study was interesting in that it utilized a comparison group, and suggested stability of change over time. However, measurement techniques were not clearly presented, and it appears that the results were again based more on clinical impression than on empirical data. Finally, the inclusion of only males in this study limits the generalizability of these results. Clinical ratings also formed the basis for an evaluation of three therapeutic camping trips. Ninety-nine male and 33 female ado-

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lescent participants were rated by counselors on six personality dimensions following the completion of each of three camping trips. The results suggested that the males became significantly less dependent following the third trip, whereas the females did not experience significant change (Burdsal & Force, 1983). Once again, the results of this study are suspect because of the lack of objective data collection instruments and the heavy reliance on clinical impressions. Thus, clearly the literature on the effectiveness of outdoor approaches to therapy with adolescents is fraught with methodological and interpretive problems. Probably most disturbing is the lack of scientific rigor in the design and execution of the program evaluations. Most of the studies cited failed to use well designed, validated measurement instruments, and relied solely on subjective clinical impressions in drawing conclusions about outcome. Other identified problems include the lack of comparison groups, small sample sizes, and the absence of follow-up data. If the efficacy of wilderness treatment programs is to actually be examined, care must be taken to measure change in a more rigorous fashion. In an attempt to assume such an empirical posture, the present study utilizes standardized, validated instruments, and bases any conclusions drawn on these instruments. To correct for the small sample sizes reported in the literature, results from four trips using a total of 23 subjects are herein reported. Finally, multiple measurement points are included in this study to compensate for the difficulty in employing traditional control groups in this type of research.

T H E STUDY The study reported herein was designed to determine the efficacy of a particular out-of-doors treatment model, the Wilderness Therapy Program (Berman & Davis-Berman, 1989), on adolescents in outpatient counseling. This program has previously been tested on inpatients (Berman &Anton, 1988). In short, the Wilderness Therapy Program provides adolescents, in groups of six to eight male and female participants, with an intensive therapeutic experience in the wilderness in which treatment goals


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are specified and counseling is provided by licensed mental health professionals. It was predicted that positive change would be found at post-test on a variety of measures, including affect, behavioral symptoms and self-perceptions.

Method Subjects. Twenty-three adolescents, including 15 boys and 8 girls ranging in age from 13 to 18 participated in four Wilderness Therapy Program trips. Exclusionary criteria for participation included severe conduct disorders and psychotic disorders. All of the adolescents were involved in outpatient mental health counseling, and were generally dealing with family problems, relationship difficulties, depressive symptoms, and difficulty with anger and impulse control. Data Collection and Instrumentation. Four instruments were administered to all participants at pre-test and post-test. The locus of control, self-efficacy, and self-esteem inventories were administered at these times, while the behavioral symptom inventory was given at admission, pre-test, post-test, and discharge. 1. The Internal-External Locus of Control Scale (Rotter, 1966) (I-E) measures the extent to which the individual feels that control is inside or outside of one's self. Respondents are asked to indicate which of a pair of statements most accurately describes one's beliefs. Examples of such items include: "a) Many of the unhappy things in people's lives are partly due to bad luck, and b) People's misfortunes result from the mistakes they make." The inventory consists of 29 such pairs, with higher scores suggesting greater externality. 2. Perceptions of self-efficacy were measured using an existing inventory (Sherer et al., 1982). Respondents are asked to indicate whether or not a statement describes their typical way of responding, by answering yes or no. Examples of some of the items include: "I give up easily" and "I am a self reliant person." Seventeen such items are included, with a possible score range of 0 to 17, with higher scores indicating increased levels of perceived self-efficacy.

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3. Self-esteem was assessed using the Piers-Harris self-esteem inventory (Piers & Harris, 1969). Respondents are asked to answer "yes" or "no" to 80 items. Examples of some of these items include: "I have good ideas" and "My looks bother me."

4. Behavioral Symptoms were measured by the Behavioral Symptom Inventory (BSI; Derogatis, 1975) which was administered at the following times: upon admission, at pre-test, post-test, discharge (2 weeks following post-test). These multiple administrations allow comparisons of rate of change before, during and after the trip. The BSI inventory asks respondents to indicate whether or not they experienced certain symptoms in the past 7 days. Examples of some of these symptoms include: poor appetite, feeling blue, and feeling inferior to others (Derogatis, 1975). This inventory contains 50 such symptoms, with a possible score range of 0 to 50, with high scores suggesting greater distress. In addition to these standardized instruments, some measures were developed and used specifically for the program. The number of critical incidents on the trip per child per day was recorded. Critical incidents were defined as verbal or physical attacks, harming oneself or others, running away, or refusing to cooperate. Individual treatment plan goals (ITP) were also developed for each participant prior to the departure of the trip. Ratings of 1 to 7 on the frequency of meeting these goals were given by the Wilderness Therapy staff at pre-test and post-test. Finally, a Wilderness Therapy Checklist (WTC) was developed, and assessed peer interaction, affect, self-esteem, response initiation and conflict on a 7 point scale, with higher numbers suggesting greater frequency of occurrence. Once again, the Wilderness Therapy staff rated each participant at pre-test and at post-test.

Procedure Four 10 to 13 day backpacking trips were conducted in Allegheny National Forest in Pennsylvania and Daniel Boone National Forest in Kentucky. Prior to the departure of the trips, participants and their families attended two orientation meetings. During these sessions, a number of consent forms were signed, equipment needs reviewed, pre-test instruments were administered, and individual treatment plan (ITP) goals were de-


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veloped by the adolescent, the parents and the Wilderness Therapy staff. Counseling was an integral c o m p o n e n t of these trips. Group therapy was held on a daily basis and was conducted by a licensed professional. Individual therapy was available, as needed, but the emphasis of the Wilderness Therapy Program was to use the group as the primary mechanism for change. Participants were responsible for another c o m p o n e n t of their treatment, a journal, to which daily contributions were made. T h e first two days of the actual trips were spent in base camp, where the participants were instructed in basic camping, backpacking, and wilderness safety skills. Participants also engaged in structured activities geared toward increasing group cohesiveness, self-esteem and trust. Following this preparatory work, the groups departed for a week on the backpack trail. T h r o u g h o u t the program, participants were required to take responsibility for themselves in a n u m b e r of ways. First, all were expected to successfully meet the physical challenges of a rigorous backpacking experience and to function well beyond their usual expectations of outdoor abilities. Second, every day, each individual had to work in cooperation with assigned partners in all aspects of the backpacking trip. Following their return from the trip, all of the adolescents were post-tested on the study instruments. Two weeks following termination of the trip, the groups again met to process and share insights and changes developed on the trip, and to devise ways of incorporating these changes into their everyday family lives. Results

Pre-test post-test comparisons were p e r f o r m e d on all of the measures. Utilizing a paired T-test procedure, significant change at post-test was seen in self-efficacy (pre-test M = 10.5, post-test M = 13; t(22) = 4.34, p < .01) and self-esteem was also seen to be significantly higher at post-test (pre-test M = 51, post-test M = 55; t(15) = 3.18, p < .01). Finally, significant change was also seen on the BSI measure as indicated by an Analysis of Variance (F(3, 1 9 ) = 14.75, p < .01; admission M = 13.3, pre-test M = 9.3, post-test M = 7.2, discharge M = 5.5). Although par-

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ticipants tended to become more internally oriented on the locus of control scale following the Wilderness Therapy Program, (pre-test M = 9.2, post-test M = 7.6), these differences were not found to be statistically significant. Change on the measures designed specifically for the program supported the efficacy of Wilderness Therapy. The average change on the individual treatment plan goals for all participants was 2.7 on a 7 point scale. In addition, change on all dimensions of the Wilderness Therapy Checklist (WTC) was positive, with increases in affective and cooperation ratings being most prominent (mean change: affect = 2.2; cooperation = 2.0; response initiation = 1.6).

DISCUSSION The results of this study lend support to the earlier predictions. The Wilderness Therapy Program appears to have had beneficial effects on the outpatient adolescent participants. As expected, these effects appear to be most dramatic in the areas of behavioral symptoms, self-efficacy and self esteem. Significant changes were seen on these measures, with self-reported symptoms decreasing, and both self-efficacy and self-esteem increasing following the Wilderness Therapy Program. These changes suggest that Wilderness Therapy is most effective in the behavioral and affective realms with adolescent outpatients. Additionally, positive change was noted on treatment plans and on affect and cooperation. These results are consistent with literature cited which suggests the efficacy of outdoor treatment in affecting change in self-esteem, self evaluation (Adams, 1970; Burton, 1981; Hendy, 1975; Kaplan, 1974) and in the reduction of behaviorally disturbing symptoms (Berman & Anton, 1988). The present results can be compared with previous work with the Wilderness Therapy Program for inpatient adolescents, using many of the same instruments (Berman & Anton, 1988). Basically, the same pattern of change emerges for inpatients and outpatients. Replicating the pattern found for inpatients adds strength to the general findings for the Wilderness Therapy Program. This highlights the effectiveness of the Wilderness Ther-


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apy Program as an innovative therapeutic alternative to working with a variety of adolescents. An additional strength of this study is its attempt to correct for some of the methodological problems cited in the previous literature, such as biased samples (Burton, 1981; Godfrey, 1977; Hendy, 1975) and conclusions based on clinical impressions rather than on objective data (Adams, 1970; Jerstad & Selzer, 1973; Kaplan, 1974). However, more intensive work needs to be done in this regard. Studies on the efficacy of such innovative treatment approaches must operationalize their variables, and choose measurement procedures and instruments which are scientifically sound. Studies should also be done which employ larger samples in order to utilize statistical procedures in the interpretation of data. Additionally, it would be interesting to evaluate the effectiveness of wilderness treatment programs on diverse client groups, such as substance abusers, adult mental health clients, and clients in the criminal justice system. In this way, one can begin to move toward greater generalizability of the effects of such innovative programs. Finally, in evaluating the efficacy of a practice model, stability of change over time is critical. In order to address this issue, we are currently in the process of collecting one and two year follow-up data.

SOCIAL WORK PRACTICE IMPLICATIONS Important practice implications may be drawn from this study. It can be suggested that the Wilderness Therapy Program is especially applicable to social work practice. Historically, the profession of social work has defined its uniqueness in its adoption of a systems based model of practice, which truly captures the person-in-situation focus of the profession. This fundamental position is probably best illustrated through the early writings of some of the foundation theorists and model builders in social work. Bartlett's (1970, p. 116) statement is pertinent. She wrote of the "relation between the coping activity of people and the demand from the environment." Similarly, Schwartz (1961) called for an emphasis on the mediation between the individual and the social environment. Finally, Gordon (1969, p. 6) advocated for a "simultaneous dual focus on individuals and the environment."

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Innovative practice models and frames of reference have been developed as social work, as a profession, has tried to define its perspective (NASW, 1977). Clearly, the most widely accepted models, however, continue to be based in the person-in-situation focus developed so long ago (Compton & Galaway, 1989; Germain & Gitterman, 1980; Pincus & Minahan, 1973; Siporin, 1975). The Wilderness Therapy Program, as evaluated in the present article, maintains the same person-environment focus as detailed above. In fact, by intentionally selecting a difficult and challenging environment in which to work, the person-environment transactions may be intensified which may contribute to the speediness of therapeutic change (Berman & Davis-Berman, 1989). It is through such environmentally-based approaches that the uniqueness of the person-in-situation truly comes forth, which serves to define and distinguish the social work profession from other professional groups.

REFERENCES Adams, W. D. (1970). Survival training: Its effects on self-concept and selected personality factors of emotionally disturbed adolescents. Dissertation Abstracts

International, 31,388B. Bartlett, H. M. (1970). The Common Base of Social Work Practice. New York: National Association of Social Workers. Berman, D. S., & Anton, M. T. (1988). A wilderness therapy program as an alternative to adolescent psychiatric hospitalization. Residential Treatment for Children & Youth, 5, 39-52. Berman, D. S., & Davis-Berman, J. L. (1989). Wilderness therapy: A therapeutic adventure for adolescents. Journal of lndependent Social Work, 3, 65-78. Burdsal, C., & Force, R. C. (1983). An examination of counselor ratings of behavior problem youth in an early stage, community-based intervention program. Journal of Clinical Psychology, 39, 353-360. Burton, L. M (1981). Critical analysis and review of the research on outward bound and related programs. Dissertation Abstracts International, 42, 1581-B. Compton, B. R., & Galaway, B. (1989). Social Work Processes. (4th ed.). Belmont, CA.: Wadsworth Publishing Co. Derogatis, L. R. (1975). The Brief Symptom Inventory. Riverwood, MD.: Clinical Psychometric Research. Germain, C. B., & Gitterman, A. (1980). The Life Model of Social Work Practice. New York: Columbia University Press. Godfrey, R. (1977). Outward Bound: Schools of the Possible. Garden City, NY: Anchor Press. Gordon, W. E. (1969). Basic concepts for an integrative and generative concep-


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tion of social work. In G. Hearn (Ed.), The General Systems Approach: Contributions toward a holistic conception of social work. New York: Council on Social Work Education. Hendy, C. M. (1976). Outward bound and personality: 16 PF profiles of instruction and ipsative changes in male and female students 16-19 years of age. Dissertation Abstracts International, 36(7-A), 4352-4353. Jerstad, L., & Seizer, J. (1973). Adventure experiences as treatment for residential mental patients. Therapeutic Recreation Journal, 7, 8-1. Kaplan, R. (1974). Some psychological benefits of an outdoor challenge program. Environment and Behavior, 6, i01-115. Lowry, T. P. (1974)..Camping Therapy: Its Uses in Psychiatry and Rehabilitation. Springfield, II: Charles C. Thomas. NASW, (1977). Special issue on conceptual frameworks. Social Work, 22(5). Piers, E., & Harris, D. (1969). Manual for the Piers-Harris children's self concept scale. Nashville: Counselor Recordings and Tests. Pincus, A., & Minahan, A. (1973). Social Work Practice: Model and Method. Itasca, Il.: Peacock. Rotter, J. B. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 80(1), Whole No. 609). Sherer, M., Maddux, J., Mercandante, B., Prentice-Dunn, S., Jacobs, B., & Rogers, R. (1982). The self-efficacy scale: Construction and validation. Psychological Reports, 5 1 , 6 6 3 - 6 7 1 . Schwartz, W. (1961). Social worker in the group. Proceedings of the National Conference on Social Welfare, Social Welfare Forum. New York: Columbia University Press. Siporin, M. (1975). Introduction to Social Work Practice. New York: Macmillian.