Therapy gone wild

When psychologist Steve DeBois, PhD, works with groups of troubled teens, he uses the evidence-based approaches that any good short-term residential-treatment therapist would use: cognitive behavioral therapy to combat negative thinking, journaling to help shed light on depression and anxiety, and group activities to overcome social phobia and develop greater self-confidence, to name a few.

But instead of doing this work in a fluorescent-lit treatment facility, DeBois takes the teens into the Utah high desert, where they learn ways to defeat unproductive emotional and psychological patterns while camping and hiking in a stunning landscape of mountains, pine trees and juniper bushes.

These are not Outward Bound courses or backpacking trips, DeBois says. "Those things have value unto themselves, but we offer a layer of real therapeutic work, a traditional insight-oriented approach to addressing whatever these kids' issues happen to be."

DeBois is clinical director of a program called Second Nature, one of a number of "private pay" programs — they're not covered by insurance — that are bringing empirically informed therapeutic techniques and therapists into the wilderness. The trend, which began in the mid-1990s, has burgeoned over the last decade, with more and more programs offering tailored approaches for young people with clinical diagnoses or substance use problems, adults who want to move on to new life stages, and families who need interventions that pack more punch than one or two office-based sessions.

This new brand of outdoor treatment began as a reaction to some wilderness therapy programs created in the 1970s, says psychologist and adventure therapist H.L. "Lee" Gillis, PhD, of Georgia College. Those programs lacked good oversight and were run by a mish-mash of providers, many of them unqualified and unlicensed, he and others say. At the time, many such programs were state-funded, and some took the form of "boot camps" designed to create challenging and even punishing experiences for young clients, many of whom came from the juvenile justice system. This type of treatment reached a nadir in 1994, when 16-year-old Aaron Bacon died from a treatable ulcer on a trip to southern Utah. When he complained of abdominal pain, his counselors called him a "faker," then deprived him of his sleeping bag for 14 nights and food for 11 nights.

That's when the program directors and founders of five wilderness therapy programs came together for a meeting in Salt Lake City, put their differences aside, and recognized that discussing best practices and agreeing on common principles would be best for the industry. To those ends, they created the Outdoor Behavioral Healthcare Research Cooperative to make sure these programs were properly studied and evaluated, says Keith Russell, PhD, of Western Washington University, who served as the organization's first researcher. The cooperative's members have conducted some 200 studies, currently under the direction of Michael A. Gass, PhD, of the University of New Hampshire.

"Intentionality" — planning a program's design and treatment course in thoughtful, empirically based ways — "is so important to the success of wilderness therapy," Gillis says.

How it works

Second Nature, founded in 1998, is one of the oldest of these "intentional" programs, says psychologist Andrew Erkis, PhD. He heads Erkis Consulting Group, a practice specializing in helping parents of at-risk adolescents find the most appropriate wilderness therapy and other programs, including Second Nature. Each of Second Nature's four campuses — two in Utah, one in Oregon and one in Georgia — is staffed by two or three doctoral-level psychologists as well as other mental health professionals with expertise in a variety of areas, including anxiety and depression, attention deficit disorder, Asperger's syndrome, obsessive compulsive disorder, eating disorders and trauma. (An even newer trend is to include a staff psychiatrist as part of the treatment team, Erkis notes.)

Clinical staff members conduct a thorough assessment of each child before doing anything else, says DeBois. That means young people — who have both diagnosable mental health conditions and a typical range of adolescent problems including rebellion, self-doubt and substance use — are placed with therapists and peers who match their issues, says DeBois. Most adolescent groups are single-gender, while most young adult programs are co-ed. In addition, these courses are "open enrollment," meaning that young people in various stages of the process live together in the same group, with new kids entering all the time and graduates exiting. "There's a lot of peer mentoring and peer modeling," DeBois says.

Once the teens are properly assessed, the wilderness setting, the tailored therapy and the lengthy stay — which averages eight to 10 weeks — provide a crucible for growth, says DeBois. That's because the wilderness is devoid of escape hatches: Hiding in one's room playing computer games is not an option. In addition, the longer stay helps break down defensive barriers, with young people typically going through an avoidance stage, a learning stage, and a stage in which they start to internalize healthier thinking and behavior patterns.

"A big part of this experience is helping students experience for themselves a greater sense of self-efficacy and internal locus of control," DeBois says.

Nature is a catalyst, too. That's because it's empowering to realize that you can survive in the wilderness, Erkis says. In addition, the outdoors nurtures physical health, which in turn fosters mental health.

"They're in an emotionally safe place, they're not going anywhere, and by the way, they're exercising, they're eating well, they're sleeping well — they're starting to look and feel great," Erkis says.

The setting also allows psychologists to work in fun and nonpathologizing ways. For instance, DeBois treated an extremely shy boy who was deeply anxious that others would judge him harshly. DeBois suggested the staff play charades and give the boy an assignment that made him the center of attention — an exercise that helped the boy see that being in the spotlight wasn't so scary.

"Being in this kind of setting allows therapy to happen in this backdoor way where it doesn't feel like therapy," DeBois says.

Family dynamics

Other psychologists are taking families, adults and couples out to the wilderness for therapeutic experiences. Psychologist Scott Bandoroff, PhD, launched the field of "wilderness family therapy" in 1990 when he observed that young people who had made great gains on wilderness therapy trips tended to lose ground when they got home, the result of returning to negative family dynamics.

Given the difficulty of scheduling time for a whole family, plus the cost of these ventures, Bandoroff tends to take families out for three-day weekends. These sessions can make a big impact, he has found, thanks to a combination of being removed from daily life and its distractions; doing exercises to build trust and teamwork; taking solo trips where family members have a chance to ponder their individual issues and roles; and participating in group activities that end with a reward, like a beautiful mountain view. Families also set and agree on goals based on what they've learned, so they can continue to work on issues raised during their time out, says Bandoroff, who heads Peak Experience, a wilderness therapy training and practice firm in Ashland, Ore.

Looking to the future

These programs aren't perfect, those involved admit. For one thing, they're expensive, costing from $20,000 to $30,000 for two months. As such, they tend to be available only to wealthier clients, since insurance doesn't pay for anything but discrete therapy sessions in the wilderness, and publicly funded programs generally dried up with the 2008 recession. For another, the quality of these programs remains variable. While many programs are reputable state-licensed programs with top-notch therapists, others have more questionable credentials, Erkis says. Because so much time is spent outdoors without parental supervision, ethical, safety and health issues may also arise, so it behooves parents to find well-vetted programs, Erkis says. Finally, follow-up is a problem with some programs, though good programs make sure clients receive recommendations for additional care or placement if needed.

That said, research is starting to show that some of these programs can be effective. A 2010 Journal of Therapeutic Schools and Programs article by Ellen Behrens, PhD, and colleagues, for instance, examined several large-scale, multi-center longitudinal studies and found that youth in these programs improved significantly in mood and behavior during treatment, and that those improvements continued when they returned home. Meanwhile, in six years of tracking participants and parents over a number of programs, Second Nature researchers found significant improvements in the youngsters' overall motivation, life skills, interpersonal relationships, hope, self-confidence and emotional control both at graduation and at six-month follow-ups. Importantly, parents perceived those differences, too.

For Bandoroff, there is no doubt that the combination of being in a beautiful natural setting and working on your issues with highly trained professionals is a winning one that more psychologists should consider exploring.

"You get spoiled for life when you see how quickly change can occur," he says.

Tori DeAngelis is a writer in Syracuse, N.Y.