Dedicated to Change
The founders of Legacy Outdoor Adventures have long been leaders in supporting research in the field of wilderness therapy. Gil Hallows was one of the founders of the Outdoor Behavioral Healthcare Industry Council (OBHIC) in 1996, and its research arm, the Outdoor Behavioral Healthcare Research Cooperative (OBHRC). Gil has served on the OBHRC Steering Committee from the beginning, and has served on the NATSAP Research Committee and as NATSAP Board Liaison to the Research Committee. The previous program where Gil served as Executive Director was extensively involved in participating in all of the OBHRC research projects conducted by Dr. Keith Russell, and in collecting outcomes data in support of the NATSAP research effort. Below are some of the significant OBHIC studies:
Does Wilderness Treatment Work? Does It Last?
For this outcome study the Youth Outcome Questionnaire (YOQ) with a sample of 858 kids and their families from seven programs over a full year. The YOQ is a simple but well-researched and solid therapeutic outcome test on which higher scores indicate greater behavioral/mental health disorder. Average scores for adolescents admitted to a psychiatric hospital are about 100; average score for teens in outpatient treatment are 78; the average community adolescent score is 23. The upper limit of the normal community range is 46.
Our results showed that kids enter wilderness treatment programs with scores of about 100, as rated by their parents. (The kids believe they are much better off than that.) At discharge, ranging from three eight weeks later depending on the program, the parents scored their kids at about 49, just outside the normal community range.
At three and six months after discharge, kids’ scores rose slightly, to 56 and 57, but not statistically significantly, before trending back down to 49 again at 12 months. In other words, contrary to a common opinion about brief, intense treatments, the therapeutic and behavioral gains of outdoor behavioral healthcare treatment were sustained over 12 months.
A follow-up study published in 2004, when these clients were two to three years out of their outdoor behavioral healthcare treatment, called 88 of these families and kids (selected for their representativeness) to ask how they were doing, using a structured interview. Some of the important results:
83 percent were doing better, and 58 percent were doing well or very well. 17 percent were still "struggling."
81 percent rated outdoor behavioral healthcare treatment as effective; 10 percent split between "not effective" and “not sure” or “partially effective."
86 percent were in high school or college, or had graduated from high school and were working. Six had graduated from high school but were living at home and "doing nothing;" only five had not graduated from high school, and these were living at home and working or "doing nothing," and one was in prison.
Mental Health Issues: Depression, Anxiety and Stress
The young people in our programs also took a test, the DASS, to measure depression, anxiety and stress.
While nearly half of the 660 clients who filled out this questionnaire indicated a least mild problems in these areas, the percentages who felt these problems were for them “severe” or “extremely severe” was much smaller.
At the six month follow-up, scores continued to drop in all these areas except stress for the boys, which increased slightly, though the scores were in the mild range. Depression and anxiety were, on average for both boys and girls, squarely in the middle of the “normal” range. Not all of these changes were statistically significant, but they do show a clear real improvement.
Drugs, and Getting Motivated to Give Them Up
Our most thorough outcome studies, actually a composite of four of them done with 872 clients, were published in 2006. It established that 77 percent of the outdoor behavioral healthcare clients had substance abuse diagnoses or dual diagnoses in mental health as well as substance abuse (49 percent.) The remaining 23 percent had mental health diagnoses only, though some of them had begun to struggle with substance use as well. A long and well-constructed questionnaire, the Personal Experience Inventory (PEI) indicated that the outdoor behavioral healthcare clients with substance abuse problems scored almost as high as adolescents in residential programs for chemical dependency treatment, and both scored much higher than a community sample. Taking all clients together, 20 per cent said they had not used alcohol in the three months before treatment, and another 40 percent reported that they had used alcohol just one to five times during those three months. In a follow-up study six months after program completion, 42 percent said they did not use at all from the fourth to the sixth month following treatment, and 30 percent reported using one to five times in those three months. About eight per cent reported 10 or more uses in the fourth to the sixth months after program completion, vs. about 23 percent using that much pre-treatment. The marijuana use figures were similar, with 45 percent reporting no use to 5 uses in three months before treatment, and 44 percent using 10 to 40 or more times. After treatment, 50 percent reported abstinence for months four to six, 39 percent reported one to five uses, and less than 3 percent said they used 10 or more times. Thus, the number using not at all or infrequently increased from 45 percent to 89 percent, while the number using marijuana regularly dropped from 40 percent to 3 percent.
As is clear from the two/three year YOQ follow-up study, many outdoor behavioral healthcare clients quit using alcohol and drugs after treatment, while others do not quit entirely but seem rather to practice “harm reduction,” substantially reducing their frequency of use, and showing better control over their related behaviors. In that 2004 structured interview study of the clients in our first research program, substance abuse/dependence was a treatment issue for 75 or the 88 clients. In the two to three years since leaving wilderness treatment:
27 percent of them reported having abstained entirely.
73 percent had used or were still using at the time of the follow-up interviews. Among this group, 15 percent (12 families) reported substance abuse as a “significant problem” still.
34 percent went on to therapeutic boarding schools or NATSAP residential treatment programs.
47 percent got out-patient aftercare.
16 percent got no aftercare treatment.
Parents and kids reported that getting through school and finding new, healthier friends was a long, often difficult process.
These numbers compare favorably with federally supported outcome results from public programs. A recent DATOS study, which included 90 days of residential treatment followed by three months of out-patient therapy showed the average change of marijuana use in the 90 days before treatment to the 90 days in outpatient therapy was from 63 days to 45 days. Those figures included only the adolescents who completed the program; an unspecified percentage quit during treatment and were not included in the outcome results.
In the chemical dependency treatment field “motivation to change” has become a big issue: most substance abusers enjoy that activity and don’t see a need to stop it, even though it may be very damaging to their lives. A test called the URICA has been designed to assess readiness for change and, using that with the clients in this study, Dr. Russell established that the drop in substance abuse following treatment was almost certainly due to the effectiveness of the treatment they experienced, because the programs were able to inspire their clients to want to give up on, or significantly reduce, their use of alcohol and drugs. Entering wilderness treatment, 73 percent of our clients either had no interest in changing their behavior, or, though they might be thinking about it, were reluctant to take any action. The rest had stopped trying to ignore the problem and were beginning to participate in efforts to change. By the end of their wilderness treatment, none of our clients were still in the first phase (“uninvolved”) and just nine percent were in the second phase (“reluctant.”) The other 90 percent were either in the active participation phase or, having worked through the issues and decided to quit or seriously reduce their use, had gone on to the final phase, “maintenance” of their decisions. There was some backsliding at the six month follow up, but of the 229 clients who filled out this questionnaire at six months, 182 fit the “participation/maintenance” profile (79 percent) while 21 percent fit the “reluctant” profile. None were “uninvolved.” It is rare in the evaluation of treatment to see such strong results.
Two years later: A qualitative assessment of youth-well-being and the role of aftercare in outdoor behavioral healthcare treatment
Child & Youth Care Forum, 34(3), June 2005
This study evaluated youth well-being 24-months after the conclusion of outdoor behavioral healthcare (OBH) treatment and explored how youth transition to a variety of post-treatment settings. OBH treatment involves integrating clinical treatment approaches with wilderness expeditions that average over 50 days. Transition from OBH treatment often requires that youth and family utilize aftercare services, which are typically: (a) outpatient services, which are comprised of individualized, group or family therapy, or (b) residential services, which are comprised of residential treatment centers, therapeutic boarding schools, and others. The results suggest that 80% of parents and 95% of youths perceived OBH treatment as effective, the majority of clients were doing well in school, and family communication had improved. Aftercare was utilized by 85% of the youths and was perceived as a crucial component in facilitating the transition from an intensive wilderness experience to family, peer and school environments. Results also indicated that many continued to use alcohol and/or drugs to varying degrees, had legal problems, and still had issues forming friendships with peers. OBH treatment was perceived as being a necessary and effective step in helping youths address, and eventually overcome, emotional and psychological issues that were driving destructive behavior prior to OBH treatment.
Mental Health Issues: Depression, Anxiety and Stress
The Therapeutic Alliance
Risk in the Wilderness
OBH is Safer than Being at Home for the Average Teen
Engaging Resistant Clients
Family Involvement (PDF)
Assessing treatment outcomes in outdoor behavioral healthcare (OBH) using the Youth Outcome Questionnaire,
Family involvement and outcome in adolescent wilderness treatment: A mixed methods evaluation