the treatment of adolescent populations: an institutional vs. a wilderness setting

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Journal of Child and Adolescent Group Therapy [jcag] HS088-50 May 20, 2000 13:36 Style file version Nov. 19th, 1999

Journal of Child and Adolescent Group Therapy, Vol. 10, No. 1, 2000

The Treatment of Adolescent Populations:An Institutional vs. a Wilderness Setting

Bryant Williams, M.A. 1,2

Since the turn of the century, adventure therapy has been used as an adjunctto therapy in the treatment of a variety of psychiatric populations. Adventuretherapy is a term used throughout the literature, referring to the use of outdooreducation and recreation activities as a form of therapy. Implicit to the practiceof adventure therapy is the fact that the treatment takes places in a wildernessas opposed to an institutional setting. The use of adventure therapy has been themost popular in the treatment of adolescent populations. Due to its popularity,adventure therapy has attracted a great deal of research which has repeatedlyfound both anecdotally and empirically that the treatment of adolescents in awilderness setting is more effective than in a clinical setting. The effectivenessof treating adolescents in a wilderness setting using adventure therapy is welldocumented; but not well understood. This article will examine the dynamics ofgroups in clinical and wilderness settings and offer insights about the greatereffectiveness offered in a wilderness setting.

KEY WORDS: adventure therapy; adolescents; wilderness setting; clinical setting; recidivism; groupdynamics.

INTRODUCTION

The use of adventure therapy has its root in two coincidental and separatelyoccurring events which occurred around the turn of the century. On June 5, 1901,the New York Asylum for the Insane had severe problems with overcrowding. Asa result, Dr. MacDonald made the managerial decision to place forty tubercularpsychiatric patients in tents on the asylum lawn, so they would not infect therest of the population (Caplan, 1974). This change, from indoor to outdoor life,had an unexpected and beneficial effect on these chronic and hopeless patients.

1Graduate Psychology Student, The Naropa Institute: Transpersonal Psychology Dept., Boulder, CO.2Address correspondence to Bryant Williams, 4969 Franklin Dr., Boulder CO 80301.

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1053-0800/00/0300-0047$18.00/0C© 2000 Human Sciences Press, Inc.

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Now outside, many of the patients, though previously bed-ridden or “seriouslyregressed”, showed substantial improvement in physical, mental, and behavioralhealth and were eventually discharged (Caplan, 1974). In 1906, an earthquake inSan Francisco destroyed much of Agnew Asylum, leaving many patients trappedand others without shelter, forcing them to construct tents and begin living out-of-doors. Dr. Hoisholt was astounded with the positive effects that this catastrophehad on the patients. He wrote: “Immediately following the catastrophe. . .manyworked like Trojans in the effort to rescue those caught in the wreck and in caringfor the wounded. Men and women who had been more or less constantly violentwhen confined to the building were now getting along peacefully,” (Caplan, 1974,p. 10). These two serendipitous events lead to what was known as “tent therapy,”which involved various asylums intentionally creating tent wards on their lawns(Caplan, 1974). The anecdotal reports of the time attributed the success of tenttherapy to the small group interpersonal interactions that the patients engagedin, the tranquil atmosphere of the outdoors, and a smaller staff to patient ratio(Caplan, 1974 and Kaplan and Reneau, 1974). Unfortunately, these outdoor wardseventually became as overcrowded and as understaffed as the indoor wards andwere eventually reintegrated into the asylums (Caplan, 1974).

What was known as tent therapy at the beginning of the century reemergedduring the fifties and sixties as hospitals and detention programs around the coun-try began experimenting with the use of adventure therapy as an adjunct to thetreatment of a variety of psychiatric and offender populations (Cason and Gillis,1994). Adventure therapy is a term used throughout the literature referring to theuse of outdoor education and recreation activities as a form of therapy. Implicit tothe practice of adventure therapy is the fact the treatment takes place outside asopposed to inside or more accurately in a wilderness as opposed to institutionalsetting. Adventure therapy is similar in many ways to its predecessor, tent therapy,in that it is based on small group interpersonal interactions in the outdoors. Casonand Gillis (1994) report that adventure therapy has been used with such variouspopulations as “substance abusers, developmentally disabled, rape and incest vic-tims, sexual perpetrators, psychiatric inpatients, at-risk teens, adjudicated youth,couples, and families” (p. 41). However, the populations with which this therapyhas been utilized the most and with the most success are the adolescent populations.Wright (1983) suggests that there are well over one hundred programs in the UnitedStates and Canada that provide adventure therapy to adolescent populations.

Along with the rise in popularity of this form of therapy, there has been anincrease in research seeking to determine its efficacy. The findings have regu-larly claimed that adventure therapy in a wilderness setting is a more effectiveoption when compared to treatment provided in institutional settings (Cason andGillis, 1994). Despite the numerous studies claiming its efficacy, there has beenlittle written concerning why and how this approach is more effective. This pa-per will review the relevant literature and examine the factors that lead to the

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greater effectiveness of adventure therapy in a wilderness setting in the treatmentof adolescent populations.

REVIEW OF THE LITERATURE

The national rate of recidivism for an adolescent placed in an institution forrehabilitation is 65% (Pommier and Witt 1995). Because this rate is so high, themental health and judicial systems are interested in treatment and rehabilitationalternatives that can produce lower rates of recidivism. For this reason, the studiesthat evaluate the efficacy of adventure therapy programs have looked mainly atthe issue of recidivism along with the many factors such as self esteem or locusof control that contribute to lower rates of recidivism. As a result, the small groupinterpersonal interactions that characterize adventure therapy, and directly con-tribute to it’s positive effects, have been overshadowed by rates of recidivism anddata from clinical scales.

In some cases the literature provides only blanket statements such as, “Acrossthe board these programs seem to be successful.. . .we see lowered rates of recidi-vism,” (Golins, 1978, p. 26). However, such anecdotal responses can usually bebacked up with evidence from empirical studies. Kelley and Baer (Wright, 1983)conducted a thorough and respected study in this area, involving 120 adolescent of-fenders. The treatment group participated in a twenty-six day therapeutic OutwardBound course and the control group received the routine treatment of institution-alization or parole (Wright, 1983). Nine-months following treatment, they foundthat only 20% of the treatment group in comparison to 34% of the control grouphad recidivated. At the one year mark, the treatment group’s rate of recidivism heldat 20% whereas the control group’s had risen to 42%. In their long term follow-up,five years after the experiment, 38% percent of the treatment group had recidivatedin comparison to 58% of the control group (Wright, 1983).

Adams (Berman and Berman, 1989) found similar results with an adolescentinpatient psychiatric population. His follow-up study was conducted twenty-eightmonths after the treatment group had participated in a thirty day wilderness pro-gram, and the control group had participated in the standard hospital program. Hefound that those in the wilderness program had a recidivism rate which was 15%less than those in the standard program (Berman and Berman, 1989). These studiesshow that adventure therapy in a wilderness setting is not a panacea for this pop-ulation, yet at the same time they demonstrate that adventure therapy consistentlyand significantly proves to be more effective than the routine treatment of theseadolescents.

The studies in this area which were conducted in the 70’s and early 80’sseemed to focus primarily on recidivism, whereas the later studies, conductedin the mid 80’s through the 90’s, focused primarily on the possible factors that

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contribute to lower rates of recidivism. Wright (1983) evaluated the effects of atwenty-six day adventure therapy program on the self-esteem, self-efficacy, locusof control, and problem solving skills of delinquent adolescents. Through theuse of quantitative and empirical measures he found that the 21 participants inthe treatment group showed statistically significant increases in self-esteem, self-efficacy, and internality (locus of control) in comparison to the 26 adolescents inthe control group (Wright, 1983). However, “the experimental group showed nogain at all in problem-solving skills” (Wright, 1983, p. 33).

This later finding is puzzling. It would seem logical to assume that since ad-venture therapy programs lower recidivism rates, they do this in part by providingproblem solving skills to their participants. Wright (1983) found this finding puz-zling as well and questioned the validity of his measuring instrument. He used theMEPS (Means-End Problem-Solving Procedure) which evaluates the adolescent’sability to develop a step-by-step plan to achieve their goal and the scoring relieson the individual’s ability to verbalize this process (Wright, 1983). The problemwith using this type of measure is its sole reliance on verbal skills to evaluateproblem solving skills. It does not take into account the individual’s experientialproblem solving ability. Wright (1983) mentions in the discussion of his studythat adventure “programs would be improved if changes were made in the ap-proaches used to teach problem solving” (p. 41). In other words, the programswould be strengthened if they taught problem solving skills in a verbal, as well asexperiential, fashion.

Wichman (1991) explored the effect adventure therapy had on the asocial be-havior of its participants. He found that there is a statistically significant decreasein the asocial behavior of the participants in a 30-day therapeutic wilderness pro-gram. In analyzing what contributed to the reduction in asocial behavior, he foundthat the most significant factor was the ability to interpersonally problem solve. Heused the MEPS to evaluate the participant’s ability to problem solve. The programWichman evaluated had daily groups which focused solely on problem solving inwhich the participants were encouraged and taught how to solve the problems thatarose within the group in a verbal fashion.

Studies done by both Berman and Berman (1989) and Pommier and Witt(1995) concur with the strong evidence that adventure therapy programs signifi-cantly increase the participant’s self esteem. Pommier and Witt also evaluated theprogram’s effect on the participant’s ability to have and maintain close relation-ships. They found the treatment group’s ability to maintain close relationships to besignificantly higher than that of the control group’s following the experiment and inthe post-test given four months following the experiment. In addition to evaluatingadventure therapy’s effect on the participant’s levels of self-esteem, Berman andBerman (1989) evaluated the program’s effect on symptom reduction. They foundthat the treatment group experienced a significant reduction of symptoms whenthey compared the pre- and post-test scores of the Behavioral Symptom Inventory(Berman and Berman, 1989).

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In an effort to consolidate the large body of data that has been collected onthe effect of adventure therapy on adolescents, Cason and Gillis (1994) conducteda meta-analysis. In their research they found a total of ninety-nine studies thathad been conducted in this area. However, only forty-three of these studies wereempirically sufficient to be used in the meta-analysis. In examining the overalleffect of the adventure therapy programs they found that “Adolescents who par-ticipate in adventure programming (the treatment groups) are better off than 64%who do not participate (the control groups),” (Cason and Gillis, 1994, p. 44). Morespecifically, they discovered that adventure therapy was equally effective with alladolescent populations. They reviewed and consolidated the data concerning thevarious aspects of the adolescent’s personalities that the studies claimed were pos-itively effected by the programs. In the comparison of scales related to self-esteem,locus of control, attitude, grades and clinical scales, they found that adventure ther-apy had the most statistically significant effect on the participant’s clinical scales,namely the scales of depression and anxiety (Cason and Gillis, 1994). Lastly, intheir evaluations of program length on positive effects, they found that the longerthe program the more positive the results. Unfortunately, data concerning the issueof recidivism was not included or mentioned in their meta-analysis.

The literature is consistent in empirically demonstrating that adventure ther-apy is more effective than the institutional methods of treating adolescents. Thenext question is: what is it about these programs that make them more effectivethan the institutional approaches? Kerr and Gass (1987) believe that the answerlies within the realm of group dynamics, “The use of small group developmenthas often been recognized as one of the corner stones of adventure education pro-grams,” whether the focus is “acquisition of skill, social growth or therapy” (p. 39).Their article, “A Group Development Model for Adventure Education,” appliesa typical model of group development to the group developmental processes thatoccur in an adventure therapy program (Kerr and Gass, 1987). They outline howthe stages of “(1) pre-affiliation, (2) power and control, (3) intimacy, (4) differ-entiation, and (5) separation” are played out within a group during an adventuretherapy program (Kerr and Gass, 1987, p. 39). This information is an importantstep in understanding the effectiveness of adventure therapy programs. However,the model they use can be applied to groups in any setting and, therefore, it in noway accounts for the differences in efficacy between adventure therapy programsand institutional programs.

A COMPARISON OF GROUP DYNAMICS:AN INSTITUTIONAL VS. A WILDERNESS SETTING

Because the processes and stages of group development are inherently thesame in both institutional and wilderness settings, the differences in the two set-tings’ group dynamics must lie elsewhere. My experience has led me to believe

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that the differences lie instead in the content, intensity and duration of the groupdevelopmental stages. These differences can be broken down into three categories:the relationship between the counselors and clients and issues of transference; thetime spent in group activity and the development of a social microcosm; and thetypes of activities that the groups engage in.

Transference Issues

In an institutional setting the staff work in shifts, and even though each clientis usually assigned to one counselor, they inevitably have client/staff interactionswith as many as twenty staff per week. This arrangement diffuses the adolescent’stransference amongst numerous individuals. In contrast, in an adventure therapyprogram there are normally two counselors that are with the participants twenty-four hours a day for the duration of the program, which is usually between twentyand thirty days long. In this setting, the participants are able to watch how thecounselors deal with a variety of situations, whether that is during a focused groupactivity or a more casual activity like cooking dinner. This consistent and continu-ous interaction with two authority figures intensifies and focuses the adolescents’transference issues (Marx, 1988).

Marx (1988) believes that the majority of adolescents who end up in the judi-cial or mental health system have a history of some form abuse or neglect, whichresults in extreme distrust of adults in positions of authority. Therefore, the ado-lescent’s primary transference issue involves lack of trust. When an adolescent isplaced in a setting which promotes diffusion of their transference issues, they haveless opportunity to develop and work through their transference dynamic. For thisreason, Marx (1988) believes that “traditionally structured treatment systems havedifficulty reaching needy or at risk teens” (p. 517). In contrast, when an adolescentis in an environment that intensifies and focuses his or her transference he or shehas the opportunity to work through it. Marx (1988) goes so far as to say that theintensity of the counselor-client interaction in the wilderness setting allows theadolescent to work through his or her transference issues more rapidly than ina clinical setting. This is accomplished in part because the adolescent discoversrather quickly that the counselors in the wilderness setting have very practicalthings which the adolescent needs, such as knowledge of how to stay warm, howto fix a broken stove in the rain or how to safely cross a raging river. This set-ting naturally offers situations in which the group must trust the counselors, andin which individuals will tend to differentiate between the counselors and pastauthority figures. As a result, a powerful therapeutic alliance develops which isnecessary for successful treatment (Marx, 1988). In a clinical setting a counselormust rely solely on his or her behavior during group or individual sessions to de-velop this alliance. This amount of contact is often inadequate for the mistrustingadolescent and therefore the relationship may become and remain stuck in dealingsolely with resistant transference dynamics.

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The Creation of a Social Microcosm

The second major difference between adventure therapy programs in a wilder-ness setting and programs in an institutional setting involves the amount of timethe adolescents spend in group interaction. In a clinical setting, focused group in-teraction occurs in specific blocks of time and, depending on the program, the totaltime spent in group interaction ranges from two to four or five hours per day. In anadventure therapy program, focused group interaction is a continuous part of theprogram. The group must coordinate and work together to accomplish a numberof necessary tasks each day which include: how and when to wake up in morning;cooking and cleaning up after meals; packing up camp; traveling to the next camp;making route finding and group pace decisions; finding a suitable place to set upthe next camp; setting up camp; and participating in the evening therapy group.Even though the participants spend a large portion of the day in group interaction,it is not automatically therapeutic. What makes a group therapeutic in either thewilderness or clinical setting is when the group achieves what Yalom (1995) refersto as a “social microcosm.” This occurs “if the group is so conducted that themembers can behave in an unguarded, unselfconscious manner, they will, mostvividly recreate and display their pathology in the group” (Yalom, 1995, p. 39).

The increased amount of time spent in group interaction in an adventure ther-apy program leads to the creation of a social microcosm more rapidly than in aclinical setting. The very real and stressful situations that are a daily part of thegroup activities in a wilderness setting increase the level of stress and tension in thegroup. This leads very rapidly to a wide variety of acting out behavior. The partic-ipant’s acting out behavior interferes with the group as-a-whole more significantlyin a wilderness setting than in a clinical setting. Many clinical settings designsystems of group consequences for individual acting out in an attempt to teachand create a positive self-regulating peer culture. Sometimes this is successful yetoften it creates yet another boundary between the staff and clients. In a wildernesssetting, if someone steals part of the group food or if someone does not set up atent correctly and it blows down in a storm, the group suffers very real and tangibleconsequences. “In Outward Bound, the group is often in a position to benefit orsuffer from individual behavior” (Ewert and Heywood, 1991, p. 598). This leadsto the natural development of positive peer pressure, and behavior changes as aresult of experiencing natural consequences.

Ewert and Heywood (1991) found the above to be true in a study they con-ducted on group development in a natural environment. They utilized the “Jonesand Bearley Group Development Assessment Questionnaire” with 198 participantsof Outward Bound courses and based their data on the 67 returned questionnaires.They found that groups in a wilderness setting progress rapidly through the latencyand adaptation phases of group development and as a result spend more time in thelater stages of integration and goal attainment (Ewert and Heywood, 1991). Thesephases developed by Jones and Bearley (Ewert and Heywood, 1991) correspond

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to the stages mentioned earlier of pre-affiliation, power and control, intimacy, anddifferentiation. Ewert and Heywood (1991) state that “it would appear that thevarious groups studied may have moved from being relatively “immature” groupswith high levels of dependency and need for orientation to becoming “sharing” or“effective” groups with high levels of cohesion, interdependence, open data flow,and problem solving ability” (p. 612–613). They believe that groups in a naturalsetting are able to gain the above level of maturity more rapidly than in other set-tings because the natural setting requires group members to function well togetherif the group is going to succeed.

Though the wilderness setting is recognized here as being highly therapeu-tic, these therapeutic processes do not occur automatically with any group thatventures into the woods. Therapeutic processes are accomplished with the skill oftrained counselors who are able to utilize the events that occur in the wilderness asopportunities for therapeutic interventions. Marx (1988) mentions that “withouta strong counseling perspective, outdoor challenge-adventure programming canbecome basically recreation programming” (p. 518). The counseling perspectiveof the counselor in a wilderness setting does not differ in any essential way fromthe counseling perspective in an institutional setting. The counselor in a wilder-ness setting utilizes the same interventions, the difference being his or her abilityto witness and use examples of the client’s behavior from a wider variety of sit-uations. These interventions use therapeutic moments; meaning behavior may beconfronted as it occurs. A group norm is established if the counselors teach theparticipants that every moment of the course is potentially therapeutic. This is alsoaccomplished in daily therapeutic groups which are similar to groups in an insti-tutional setting. The material that is processed in a group in a wilderness settingis often the unfinished business of the day, which are often metaphors for thingsthat have occurred in the participants’ daily lives outside of the wilderness.

Differences in Group Activities

Although many of the differences in the activities between an adventure ther-apy program and an institutional program have been mentioned, a few more areworth examining. Groups in an institutional environment range from talk therapygroups to psycho-educational groups. In the case of psycho-educational groups thecounselor chooses the topic according to his or her assessment of the needs of theadolescents, such as impulse control or drug and alcohol abuse issues. At times,counselors use talk therapy groups in which the adolescents may bring whatevermaterial they choose for discussion. These groups are usually exclusively verbaland may or may not capture the attention of the adolescent. As stated above, ad-venture therapy programs employ the use of this form of group but only as a meansof processing the other activities that the adolescents engage in, which are neverpurely verbal but are a combination of physical, mental and verbal. The activities

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that adventure therapy programs utilize are of an experiential nature and are natu-rally engaging for adolescents. “Outdoor adventure can be intense, physical, andemotional just like teens” (Marx, 1988, p. 517). Golins (1978) speaks to this whenhe states, “the mechanisms and properties of adventure based education virtuallyseduce the delinquent into achieving almost in spite of himself” (p. 26).

Activities such as rock climbing, rappelling, river crossings, or rafting are bytheir nature concrete. They are easy for an adolescent to engage in because ado-lescents are in the “concrete operations stage of cognitive development” (Golins,1978, p. 26). Such activities have inherent risk factors involved as well as very realconsequences, which many adolescent risk-takers thrive on. For these adolescents,they are a safe alternative to the use of drugs, stealing, or violence. In addition, theseactivities evoke a very real feeling of stress and require the adolescent to reach outto his or her group to successfully deal with these stressful feelings. They reinforcethe need for support to get through tough situations successfully. For these reasonsthe delinquent or troubled teen “stands a better chance of excelling here,” (Golins,1978).

Interestingly, no where in the literature concerning the use of adventure ther-apy with adolescents does it mention the fact that the treatment occurs outsideas opposed to inside. As mentioned in the introduction, the asylum staff reportedrepeatedly that the act of moving patients outside had dramatic positive effects.Would not the same hold true for adolescents? Being outside, as opposed to beinginside, provides the adolescent with the feeling of freedom that many automaticallyseek. This reduces resistance because they are not continually reminded that theyare institutionalized. The effect of being outside, breathing fresh air in beautifulsurroundings is therapeutic in and of itself. This is suggested by the fact that thedesign of nearly every institution, whether it is a prison or a hospital, includes acourt yard which is due to the fact that we long ago accepted the calming andtherapeutic effects of fresh air.

CONCLUSION

This paper has reviewed the relevant literature and has argued that adven-ture therapy in a wilderness setting may be a more effective treatment option foradolescents than treatment in an institutional setting. It has examined the specificcharacteristics of adventure therapy programs that make this approach more effec-tive. As a result of this exploration, the author is left wondering why we continueto provide treatment for adolescents that proves to be ineffective 65% of the time,when there is an available alternative that repeatedly proves to be more effective.Part of the reason may lie in the fact that there is such a paucity of literature avail-able which ties accepted psychological theory to the practice of adventure therapy.Therefore, it appears that a next step for the field of adventure therapy would be tofurther develop the psychological theory of this effective and alternative approachto adolescent treatment.

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REFERENCES

Berman, J. D. and Berman, D. S. (1989). The wilderness therapy program: An empirical study of itseffects with adolescents in an outpatient setting.Journal of Contemporary Psychology, 19(4),271–281.

Caplan, R. B. (1974). Early forms of camping therapy in american mental hospitals. In Lowry, T. P.(Ed.),Camping Therapy.Springfiled, IL: Thomas Books.

Cason, D. and Gillis, H. L. (1994). A meta-analysis of outdoor adventure programing with adolescents.The Journal of Experiential Education, 17(1), 40–47.

Ewert, A. and Heywood, J. (1991). Group development in the natural environment.Environment andBehavior, 23(5), 592–615.

Golins, G. L. (1978). How delinquents succeed through adventure based education.The Journal ofExperiential Education, 1(2), 26–29.

Kaplan, H. K. and Reneau, R. F. (1974). Camping for teenage psychiatric hospital patients. In Lowry,T. P. (Ed.),Camping Therapy.Springfield, IL: Thomas Books.

Kerr, P. J. and Gass, M. A. (1987). A group development model for adventure education.The Journalof Experiential Education, 10(1), 39–46.

Marx, J. D. (1988). An outdoor adventure counseling program for adolescents.Social Work, 33(6),517–520.

Pommier, J. H. and Witt, P. A. (1995). Evaluation of an outward bound school plus family trainingprogram for the juvenile status offender.Therapeutic Recreation Journal, 29(2), 86–103.

Wright, A. N. (1983). Therapeutic potential of the outward bound process: An evaluation of a treatmentprogram for juvenile delinquents.Therapeutic Recreation Journal, 17(2), 33–42.

Wichman, T. (1991). Of wilderness and circles: Evaluating a therapeutic model for wilderness adventureprograms.The Journal of Experiential Education, 14(2), 43–48.

Yalom, I. D. (1995).The theory and practice of group psychotherapy.New York, NY: Basic Books.

the treatment of adolescent populations: an institutional vs. a wilderness setting

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