Running head:  ADVENTURE THERAPY

 

 

 

 

 

Adventure-Based Therapy:  Theory, Characteristics, Ethics, and Research

A paper written to fulfill the comprehensive examination requirement

Areas:  Psychotherapy, Ethics, Methodology

 

 

 

 

 

Sandra L. Newes, MA

Doctoral Candidate

The Pennsylvania State University


ABSTRACT

 

This paper is one of the first attempts to link established clinical theory with the available theory of AT, as well as one of the first attempts to examine the AT field through an objective scientific lens. First, a critical analysis of the clinical and theoretical basis of adventure therapy is offered.  Second, similarities between adventure therapy and more traditional modalities, including object relations, cognitive, humanistic, and behavioral therapy are presented.   Third, ethical issues in AT are discussed.  Fourth, the outcome research in AT is reviewed.  Finally, a delineation of present and future methodological considerations in AT is put forth.  Thus, this proposal seeks to lay the groundwork for empirical applications to a developing therapeutic framework.

 


Chapter 1

 

 

OVERVIEW

 

 

Chapter one of this review consists of an overview of the paper, including a statement of purpose and some broad shortcomings of the literature.  Chapter two is focused on an overall description of adventure-based therapy (AT), and includes sections which discuss the history, the theory, and the definition of AT.  In an attempt at further characterizing the field, the next section compares levels of expertise of some AT practitioners to standard mental health practitioners. The final sections of the chapter will focus on the goals of AT and the specific characteristics of AT.  Chapter three focuses on ethical issues in AT, with an emphasis on how these ethical issues relate to the APA ethical principles.  Chapter four provides an overview of the outcome research in AT; outcome with adults, outcome with adolescents, and outcome as it relates to client characteristics.  Finally, chapter five offers a discussion of the present and future methodological considerations in AT research, and ends with a call for research examining the impact of client characteristics on AT outcome.

 

Statement of  Purpose

Adventure-based therapy (AT) is gradually emerging as an addition to the field of therapy, employing diverse methods and serving such diverse populations as court ordered juvenile delinquents, the mentally ill, PTSD sufferers, the disabled, substance abusers, eating disordered individuals, sexual abuse survivors, as well as normal populations.  Since the introduction of Outward Bound programming in the United States during the 1960’s, AT has been purported to be a potentially unique therapeutic modality that can be used either independently or as an adjunct to other forms of psychotherapy. 

This paper is one of the first attempts to link established clinical theory with the available theory of AT.  This paper is also one of the first attempts to examine the AT field through an objective scientific lens.  Therefore, it is intended as a preliminary movement towards a much needed increase in legitimate scientific examination of the field of AT and, as such, can potentially be viewed as the first step of the many that are necessary in order to provide empirical support for any claims of treatment efficacy in this area. 

In order to accomplish this goal, first an analysis of the theoretical and clinical characteristics of AT is offered.  Second, similarities are examined between AT and more traditional modalities, including object relations, cognitive, humanistic psychology, and behavioral theory are presented. Third, the ethical principles of AT are discussed, with a particular emphasis on areas of overlap and contraction with the APA ethical principles.  Next, a review of the literature in AT is provided.   Finally, the closing chapter will summarize the common methodological errors found in the AT literature, and explore suggestions for future empirical exploration in the area within the framework provided for psychotherapy outcome research.  This final section will close with an articulation of the need for individual difference-based research in AT. 

It is of note that this paper is not intended as an in-depth comparison of AT with any one theoretical or empirical body, rather it is intended as an overview of potential similarities that AT shares with other theories in clinical psychology.  As such, reference will be made to the above noted theories, as well as others, without an in-depth exploration of each.  Whereas such an analysis may be recognizably important for future empirical and theoretical research which could scientifically explore such similarities, such an in depth empirically-based formulation of the relationship between the process of AT and any of these areas specifically is not the intent of this paper.  Instead, this paper seeks to lay the groundwork for future empirical applications to a developing therapeutic framework.

It is also important to state prior to beginning this examination that AT has not met the rigorous criteria established for an empirically validated treatment (Chambless & Hollon, 1998), nor has it been subjected to the high-level of empirical analysis necessary in order to truly begin scientifically evaluating claims of treatment efficacy. In fact, many of the studies do not utilize such basic design considerations as random assignment and appropriate comparison groups.  In addition, no studies have been conducted comparing AT to other established forms of treatment.  There are also very limited data available on client characteristics and of those which are available, none are based on clinically relevant diagnostic criteria.  The theoretical basis of AT is also in the early developmental stages and is unsupported by any empirical data.

While this type of treatment, its claims of efficacy, and its theoretical basis are as yet scientifically unsupported, it is a treatment whose use is clearly on the rise.  In fact, in 1993, the Association for Experiential Education (AEE) published a Directory of Experiential Therapy and Adventure-based Counseling Programs which included 257 programs nationwide which were self-identified as adventure-based therapy programs.  This number has almost certainly expanded since that time.  Of note as well is the fact that at the Second Annual International Adventure Therapy Conference in Munich, Germany (March, 2000), there were presenters from 43 different countries.  This is indicative of the expansion of adventure-based therapy internationally as well.  

Given the increasingly widespread use of such interventions, and its particular use as a government funded alternative to juvenile incarceration, it is important to subject the field to informed critical analysis.  The AT field is early in its development and as such, the methodologies and theories are still rudimentary in their development and usage.  However, with the relatively recent growth of such treatment programs this type of scientific scrutiny is vital and can potentially contribute towards an overall movement in AT research toward the direction of scientific rigor. Such an increase in rigor is necessary given the state of the literature, and will be thoroughly addressed in later sections.

Beyond the lack of solid empirical data, one additional problem with much of the AT literature that must be noted early in this discussion is that the intended audience for the literature has often been practicing adventure therapists and others involved in the outdoor field, as well as laypersons who are attempting to gain a basic understanding of adventure-based therapy.  Rarely, if ever, has writing in AT been targeted at an audience highly trained and versed in both clinical theories and empirically-based research, and there are very few published articles addressing adventure-based therapy in the well-respected APA journals. 

In some ways, this has resulted in much of the literature specific to AT having been developed in a type of vacuum.  This literature has rarely been subjected to close scrutiny and a portion of it can be thought of in some ways as analogous to “preaching to the choir”.  As such, much of the language used and the concepts put forward by may seem overly simplistic to an audience highly skilled in the aforementioned areas of clinical theory and empirical social science.  With this in mind, the reader is cautioned to recognize that the early developmental context referred to above has provided the environment for much of this published writing.  Unfortunately, this is simply reflective of the state of the field.

To complete this overview, it must be noted also that while this discussion will focus on articulating both the proposed theoretical basis of AT and the empirical studies that have been conducted in this area, it is important to note that this articulation is not intended as a statement of support for adventure-based therapy as an independent therapeutic modality unsupported by other forms of treatment.  It is also important to note that is this discussion is in no way intended to advocate for the usage of such treatment without ongoing empirical examination.


Chapter 2

 

ADVENTURE-BASED THERAPY

           

This chapter will first focus on examining the history, the theory, and the definition of AT.  In an attempt at further characterizing the field, the next section is compares some AT practices to standard mental health practices.  This contributes to defining AT by briefly focusing on one specific area that AT may fall short of standard practice, in a sense defining AT by what it is not.  The final two sections will focus on the goals of AT and the specific characteristics of AT.

 

History of Adventure-Based Therapy

 

Kurt Hahn, the founder of Outward Bound , is credited as being the first person to formally incorporate experiential education in a wilderness context.  In the 1920s, Hahn, a German educator, founded the Salem school in Germany; teaching his students to discover their own strengths and identities through examination of their own personal experience.  After being imprisoned and later deported from Germany by the Nazis in the late 1930s, he immigrated to England where, in 1942, he established a program to “prepare young British seamen to survive the rigors of sailing the North Atlantic during World War II” (Bacon & Kimball, 1989, p. 117).  Through this program, he noted that while it appeared that older sailors were able to survive extreme levels of stress and trauma, many of the younger and stronger sailors would die under the same conditions.  From this observation, Hahn concluded that mental aspects were equally as important as physical fitness in survival situations.

Hahn combined his educational philosophies , wilderness and rescue training, and principles of social cooperation into an expanded program designed to help the seamen increase their resilience when experiencing the demands of war and seamanship.  Hahn later utilized these same principles in the establishment of the first Outward Bound schools, of which the first US branch opened in the early 1960s.  The program spread rapidly and by the 1970s there were numerous agencies using Outward Bound based approaches in various forms and environments (Bacon & Kimball, 1989).  Since that time, Outward Bound has evolved into an international corporation serving a wide variety of populations including youth at risk, cancer victims, sexual abuse survivors, and persons with eating disorders.   Many other populations have been served, as well as the general public.

 

Theoretical Background

 

Experiential Education

            AT is rooted tradition of “experiential education” philosophies (Kraft & Sakofs, 1985),  defined as “learning by doing, with reflection” (Gass, 1993).  Early roots of experiential education can be traced to the educational writings of Dewey (Kraft & Sakofs, 1985).  This experiential learning tradition is based on the belief that learning is a result of direct experience, and includes the premise that persons learn best when they have multiple senses actively involved in learning.  By increasing the intensity of the mental and physical demands of learning, the participant “engages all sensory systems in a learning and change process” (Crisp, 1998).   Psychological research on information processing provides some support of this premise, indicating that multi-sensory processing accounts for a higher level of cognitive activity and increased memory.  Applied specifically to the context of AT, the multi-sensory level of the therapeutic experience inherent in adventure activities may account  for the high level of change  reported by practitioners (Crisp, 1998), thereby suggesting that “integration of experience may be more deeply anchored for the client because of this broad [sensory] base.” (Crisp, 1998, p. 67).  

Experiential education theory also postulates that active learning is often more valuable for the learner because the participant is directly responsible for and involved in the process.  In addition, experiential learning theory is based on the belief that individuals learn when placed outside of their comfort zones and into a state of dissonance.  Learning is then assumed to occur through the necessary changes required to achieve personal equilibrium (i.e., modern dissonance theory).  Kraft and Sakofs (1985) outline several elements inherent to this experiential education process:

     “1.  The learner is a participant rather than a spectator in learning.

2.     The learning activities require personal motivation in the form of energy,

involvement, and responsibility.

3.     The learning activity is real and meaningful in terms of natural consequences for the learner.

4.     Reflection is a critical element in the learning process.

5.     Learning must have present as well as future relevance for the learner and the society in which he/she is a member. “(cited in Gass, 1993, p. 4).

 

In experiential classrooms, individuals are placed in “real life” situations in which it is necessary to employ problem-solving or otherwise creative methods of working with the environment or context at hand.  Therefore, effective experiential activities involve the participant in situations in which they must take some form of action to successfully cope with their surroundings.  Such activities may take the form of outdoor pursuits such as hiking, rock climbing, or kayaking, but also include team-based initiatives or games. 

 

The Link to Therapy

Since the advent of Outward Bound, these types of experiential education programs have been expanded into therapeutic settings.  Gass (1993) has reworked the above experiential education principles and discusses how these principles can be applied to therapy.     

    “ 1.  The client becomes a participant rather than a spectator in therapy.

2.     Therapeutic activities require client motivation in the form of energy,  

involvement, and responsibility.

3.     Therapeutic activities are real and meaningful in terms of natural consequences for the client.

4.     Reflection is a critical element of the therapeutic process.

5.     Functional change must have present as well as future relevance for clients and their society.”  (Gass, 1993, p. 5)

 

It is interesting that when examining the ideas stated above by Gass (1993) it is clear to the critical reader that these are not unique to AT.  In actuality, one can see even from these most basic statements that the theory of AT builds on the foundations and well-established premises of cognitive and cognitive-behavioral theory, humanistic theory, and elements of the interpersonal aspects of object relations theory.  Therefore, it appears from this definition that what AT may offer is a potentially unique medium for the implementation of therapeutic processes assumed to be present in many therapeutic orientations. 

 

Definition of Adventure-Based Therapy

 

Also referred to as “wilderness therapy,” “therapeutic adventure,” “adventure therapy,” and “adventure-based counseling,” AT is a therapeutic modality combining presumed therapeutic benefits of the adventure experiences and activities with those of more traditional modes of therapy.  AT utilizes a therapeutic focus and integrates group level processing and individual psychotherapy sessions as part of an overall therapeutic milieu.  While specific types of facilitation occur directly related to the activities (see section on facilitation), this processing is not associated exclusively with the activities alone.  Rather, the activities can also be conceptualized as a catalyst for the processing which occurs before, during, and after activities; a catalyst which provides concrete examples of the immediate consequences associated with individual and group actions that can be referred to by both the client and the therapist.  Therefore, therapists may begin with processing exigencies around the activities themselves and branch into other areas of relevance for clients.

As such, AT lends itself well to multimodal treatment and can be utilized as an intervention independent from other treatments or as an adjunct to other well-established treatments.  Importantly, therapists are able to use any type of therapeutic orientation they adhere to in the processing that occurs around the activities. This view contrasts with the commonly held assumption that the postulated change which may occur in AT is singularly related to the activity participation.  

Ringer (1994) defines AT as a generic term referring to a class of change-oriented, group-based experiential learning processes that occur in the context of a contractual, empowering, and empathic professional relationship.  Elements of this definition are not unique to AT and can be assumed generally in many therapeutic traditions.  However, the emphasis on “group-based experiential learning processes” in a typically outdoor and active setting is clearly a combination differentiating AT from other forms of therapy.

Interestingly, Ringer’s definition does not mention “adventure.”  This purposeful omission challenges one common misconception about AT: namely, that in order to accomplish their goals, clients must necessarily subject themselves to adrenaline-fueled feats of daring and technical skill.  The fact that “adventure” is not seen as an end unto itself distinguishes it from other types of outdoor programs devoid of therapeutic focus. In line with this definition, adventure or outdoor experiences alone are not assumed to be sufficient to facilitate deep-level therapeutic growth and change.  Instead, it is the processing of the actual experience with the client that promotes the therapeutic process. Therefore, the use of the word “adventure” may in fact be misleading and terms such as “activity-based psychotherapy” may be more appropriate (Gillis, 1992).  Unfortunately however, this term has not become one of common usage in the literature and adventure-based therapy, with all of its connotations, is the name that has become standard.

In examining this discussion, it can be seen that there are problems with delineating distinct and defining parameters of AT.  To address this problem, professionals within the field have been involved in an ongoing debate as to how to best articulate a clear definition of what is unique to AT as a treatment modality.  Such a definition must necessarily incorporate widely accepted therapeutic principles while also differentiating AT from other therapies and from other types of outdoor adventure programs.  In an attempt to focus such definitions, Simon Crisp (1997) has stated on the Association for Experiential Education listserve what he believes to be a succinct and viable definition:

“1)  Wilderness and/or Adventure methods are utilized in the service      of  therapeutic practice.  Therapeutic practice involves;

        a) the identification of a problem the client presents with,

        b) application of a theoretical framework based on a theory of           personality, behavioral and psychological problems and process of change that explains the origin and nature of the problem,

        c) selection of strategies of client management and method(s) of intervention which logically relate to b),

        d) strategies and methods are routinely reviewed and modified according to client need.

 

2)    Professional relationship between therapist and client with the following characteristics;

        a) therapist brings to the relationship training and experience necessary and appropriate to meet the needs of the client, including a capacity to manage any potentially competing needs of the therapist,

        b) a contract is formed between therapist and client about the aims, limits, methods and expected outcomes of therapy,

        c) therapist works towards the best interests of the client and holds this at all times the over-riding principle in determining the actions of the therapist,

d)     therapist acts to protect the client from harm (physical and psychological). “(personal communication, 1997).

 

Once again, the singularly unique aspect of this definition is the emphasis on activities as a means of accomplishing the other common therapeutic goals.  Again, it is also this focus on the use of activities to accomplish said goals which seems to differentiate AT from most other therapeutic orientations. 

Based on this, perhaps AT can be best be seen as an activity-based approach to treatment that attempts to meet similar goals as do other treatments.  Therefore, what must be parceled out as theoretically unique to AT is the mechanism by which AT can accomplish these goals in ways that are more efficacious than other treatments for particular clients.  This is a question that remains as yet unanswered.  Simply put, it is essential that the area of AT begin holding itself accountable for answering the questions posed to all other treatments: Is this treatment effective?  For whom, and under what circumstances?

Thought of in this way, AT can begin to be seen as more similar to other types of treatments than different.  The logical assumption should follow then that AT is assumed to operate under the same scientific and clinical umbrella as other mental health treatments, and obviously practitioners of AT should  be held accountable to the same standards as other practicing mental health professionals.  Unfortunately, in reality this is not always the case.  For reasons that remain unclear, AT is often presented by its proponents as though it is a unique and separate entity, an entity somehow not responsible for upholding such standards.  This presents a clear contradiction between established standards of mental health practice and AT.

 

 

Adventure-Based Therapy Practitice vs. Standard Mental Health Practice

 

 

            Discrepancies between AT and standard mental health practices can seen through an examination of the training levels of adventure-based practitioners in therapeutic skills, the required adherence to ethical standards in the AT field, and the level of theoretical knowledge of adventure-based practitioners.

The first clear discrepancy is seen is shown through a scrutiny of training levels of adventure therapists themselves.  Given that AT does focus on therapeutic goals similar to other mental health treatments, it seems necessary that persons employed in the role of adventure therapists are skilled not only in “hard skills” ( i.e., wilderness experience, climbing, hiking, team initiatives), but are also skilled in the techniques and applications of psychological intervention (soft skills).

Unfortunately, it appears that reality may not reflect this combined necessity.  Berman (1995) conducted a straightforward survey asking about the training of adventure-based therapy practitioners.  Berman’s results show that many adventure-based therapy programs in the United States employ persons to facilitate adventure-based programming who are lacking in such “soft skill” areas.  This is clearly a concern for the continued use of AT treatments, and could potentially open such programs to the possibility of serious ethical violations. 

While such concerns are currently being addressed by the leaders within the field (for further information, the reader is urged to contact the Therapeutic Adventure Professional Group(TAPG)  of the Association for Experiential Education (AEE)), this is an area of AT easily subjected to well-justified criticism.  Given the fact that the AT field is in its early developmental stages, such issues undoubtedly will continue to arise until a solid set of mandates and guidelines regarding such competencies are established. 

Related to this, another discrepancy between AT and mental health is that while at present such a set of ethical guidelines for AT do exist, they are not actually enforceable.  Unlike the APA ethical standards, an AT professional cannot be held accountable to maintain these ethical principles in their practice, nor is there any governing body which limits which types of programs can call themselves “adventure-based therapy”.    If it can be assumed that AT should be thought of as similar to other types of mental health treatment, it is logical to wonder why the AT field is not held to such standards.  Presently however, this question remains to be answered.  The area of ethics in AT will be further discussed later in this paper.

Another seemingly obvious standard of mental health treatment commonly overlooked in the AT field is the assumption that treatment should be solidly informed by a solid foundation in psychological theory and application.  However, a survey of 31 wilderness programs specializing in adventure-based therapy found that very few of the programs contacted were able to identify what type of therapeutic process they were utilizing with their clients and tended to have little or no research to support their programs (Davis-Berman, Berman, & Capone, 1994).  This is another clear problem within the field.  While there are numerous attempts being made currently to delineate the theories and processes of AT, it appears that much of this information is not reaching the actual practitioners.  It seems possible, therefore, that there are many people working within the AT field who may be operating outside of the realm of accepted clinical practice.

It is of note that while AT defines itself as meeting the same therapeutic goals as other treatment modalities, the above two studies provide evidence suggesting that there may be an underlying belief in the field that AT is unique enough that it is unnecessary for adventure-based practitioners to be held to the same standards of expertise as other therapists.  Not only is this a clear contradiction from established practice, it is also a fairly naive claim.  The informed reader obviously wonders how is it that adventure therapists can be expected to work effectively with clients and meet stated therapeutic goals at least as well as other treatments when many of the therapists themselves are simply not as well grounded in the theories and practice of psychotherapy.  Interestingly, leading members of the AT field are involved in an ongoing debate regarding this issue, with some advocating for a required level of competency as reflected by a specified level of training, and others who advocate “training through experience”. This discussion may reflect a presently existing division one finds between those AT practitioners who have followed the more established route of academic and clinical training and those who have learned their clinical skills through direct experience.

From the standpoint of clinical psychology, this appears to be simply a moot point.  The eventual outcome to such a debate obviously must involve holding AT to the same standards of care as are other mental health treatments.  Simply put, while AT may have some unique elements, to be instituted as a viable therapeutic modality AT must adhere to the same established therapeutic standards as do all other treatments.  However, in order for this change to occur there must be further efforts made to establish a sense that AT shares more similarities with other mental health treatments than was previously assumed.  It is only with the establishment of such a belief, as well as a clear semantic and theoretical link, that AT will in actuality operate under the aforementioned umbrella of scientific and clinical practice.

            As the discussion in this and the preceding section illustrate, the AT field has not reached consensus on what constitutes an adventure therapy program in definition, theory, or in application.  In addition, there appears to be an underlying assumption that while AT may involve working towards therapeutic goals and may endorse therapeutic principles, AT is somehow uniquely different enough to not be held accountable to the same standards as are other mental health treatments. 

            To add to the confusion on this level, a wide variety of organizations and agencies consider themselves to fall within the realm of adventure-based therapy.  Such organizations employ widely differing levels and types of adventure programming, thus  it is difficult to get an exact sense of what is meant by the term “adventure-based therapy.  Therefore, it may be helpful to focus the discussion on the goals of AT.  The reader will also be given increased knowledge and understanding of the goals of AT in the following section which delineates the specific characteristics of AT.

 

Goals of Adventure-Based Therapy

 

AT proponents have articulated a variety of goals that may be associated with the approach. While recognizably unsupported by solid empirical data, as well as not clearly linked to the reduction of pathological symptomatology, the following section will broadly summarize these interconnected goals. First, clients are thought to generally increase in self-awareness, leading to an increased recognition of behavioral consequences and available choices; second, clients are thought to learn healthier coping strategies leading to increased environmental control; third, through AT, clients are thought to be provided tangible evidence of success, thereby disproving negative self-conceptions and leading to a more positive self-concept; fourth, clients are thought to learn creative problem-solving, communication, and cooperation skills; and fifth, AT is thought to facilitate realistic appraisal of individual strengths, weaknesses, and self-imposed limitations.  Ultimately, this increased awareness is thought to lead to better decision-making.  

Overall, AT programs have the overriding goal of an increasing self-awareness in a variety of domains.  In line with this, it is thought by AT theorists that connections between behavior and the results of such behavior become more apparent.  Therefore, clients can be provided with concrete examples of dysfunctional behavior and shown that alternative behavioral and interpersonal choices can lead to success.  Relatedly, Bandoroff (1989) argues that adventure activities, with the feedback and consequences available through such experiences, provide learning that enables participants to begin regulating their own behavior.   Amesberger (1998) expands on this goal, noting that AT involves:

“….the reflection on internalized norms and values with the aim to support a person to find new and more suitable structures for his or her life.  Destructive and dysfunctional behaviors or emotions should be recognized in their effects, as well as helpful and effective ones.” (p.29).

 

Of note is the fact that these tenets are clearly embedded in the therapeutic process itself.

Taylor (1989)  postulates that that the exposure to uncertainty or ambiguity accompanied by increases in levels of confidence and skill that can be achieved through the AT process will facilitate a healthier coping response. It is believed that as clients learn and use new modes of coping they gain greater control of their environment (Nadler & Luckner, 1992).  It is hoped that by coping with the treatment environment in new ways, clients can learn to achieve increased personal and environmental control outside of the treatment.  This is an experience which may be novel for many clients.

According to Herbert (1996), through AT “persons challenge themselves, and in doing so, (re)learn something about themselves.” (p.5).  To accomplish this, mastery tasks, or initial successes, associated with the activities counteract and disprove internally focused negative self-evaluations, learned helplessness, and dependency (Kimball & Bacon, 1993) at a time when such processes may be intensely activated.  This heightened activation combined with concrete evidence of success may facilitate further learning.  Ultimately, feelings of success and control also associated with the mastery tasks can then serve as additional reinforcers to support changed behaviors.  Thus, it is a circular process of interpersonal and intrapersonal activation, success, and reinforcement. 

Priest and Baillie (1987) discuss additional possibilities for client change, stating that “The aim of adventure education is to create astute adventurers: people who are correct in their perceptions of individual competence and situational risk” (p. 18). ).  Relatedly, through AT, clients can learn skills related to problem-solving, cooperation, communication, and facing challenge (Herbert, 1996).  It is thought that through this process, clients learn to more realistically appraise their own personal strengths and weaknesses, both on a personal and an interpersonal level. 

Through this process, clients begin to recognize their own self-imposed limitations and increase in their awareness of available choices, thus becoming better able to accept responsibility for their level of success or failure. As clients increase in this self-knowledge and self-awareness, it is believed that they are ultimately able to make more realistic and healthy decisions.  These are important skills many clients lack. Moreover, Taylor (1989) notes that the increased levels of confidence, skill, and self-awareness that participants may gain through AT encourages clients to see uncertainty as a challenge and not a threat, a change with potentially far-reaching positive consequences for clients.

            Ultimately, these proposed changes can perhaps be summarized in this inherent underlying assumption embedded within the adventure-based therapy literature: the assumption that by becoming aware of available choices, and by experimenting with different behaviors in a novel environment where one is receiving immediate and realistic feedback, clients can learn to actively influence their probability of success.  Furthermore, through AT clients learn to demonstrate personal competencies, build upon skills, accept personal responsibility, more accurately assess themselves, and maintain a higher degree of control over their environment.  It is also believed that having an increased capacity to regulate one’s own behavior will facilitate further increases in levels of self-awareness, competence and a more internal sense of control of one’s own world.

It is important to note once again that these assumptions and goals are not unique to AT.  In fact, statements such as above with their emphasis on self-awareness and the interpretations of challenge vs. threat carry clear elements of humanistic theory, and the focus on self-knowledge and the increased awareness of available choices directly parallels the humanistic tradition (Csikszentmihaly, 1990; Raskin, & Rogers, 1989;  Maslow, 1971).   In addition, one can see elements of cognitive, behavioral, and object relations theory embedded in this discussion of the goals of AT.  Such similarities will be summarized in detail in a later section.

It is also important to point out that the discussion of the goals of AT involves sweeping and unsubstantiated claims with little empirical support.  In addition, in the examination of such goals one can see very little that is focused on the alleviation symptomatology specifically relevant to psychopathology.  In some ways this parallels the state of the literature, as it will be seen that no studies have utilized measures of clinically relevant symptom reduction.  However, given the possibility of parallels between AT and such well-established therapeutic orientations, it may have potential therapeutic benefit and as such is deserving of continued investigation.  Further parallels between AT and other therapeutic traditions will be seen in throughout the discussion of the specific characteristics of AT.

 

Characteristics of Adventure Therapy 

 

Having discussed the history, theoretical background, definition, some basic discrepancies between AT practice and standard mental health, and the goals of AT, a discussion of the specific characteristics of AT is warranted.  Thirteen characteristics, including those delineated by Kimball and Bacon (1993), will be discussed in turn: (1) multiple treatment formats, (2) group focus, (3) processing, (4) applicability to multimodal treatment, (5) sequencing of activities, (6) perceived risk, (7) unfamiliar environment, (8) challenge by choice, (9) provision of concrete consequences, (10) goal setting, (11) trust building, (12) enjoyment, and (13) peak experience.

 

Multiple Treatment Formats

            First, adventure programs range in scope from those which incorporate adventure-based techniques with more traditional modes of therapy to those that utilize full-scale extended expeditioning as their therapeutic medium.  These types of programs are differentiated based on where the therapy is taking place, for what length of time the client

is involved, and what types of programming are being utilized (Gillis, 1995).  As Gass (1993) suggests, three main areas exist within the adventure-based therapy field.  These include (a) activity-based psychotherapy, (b) wilderness therapy, and (c) long-term residential camping

Given the diversity of programs, it is important to be clear as to what type of program is being referred to under this broad rubric of  “adventure-based therapy” when considering AT from a scientific perspective.  Unfortunately, this distinction is not always clearly noted and can be difficult to determine when examining the literature.

 

Activity-based psychotherapy

 Activity-based psychotherapy  (Gillis, 1992), occurs at the therapeutic facility of the client or at another nearby facility designed for such interventions.  This type of therapy utilizes adventure activities as one type of intervention in the client’s overall treatment plan.  The AT intervention is typically one day in duration and is used an adjunct to concurrent inpatient or outpatient treatment, although the client may participate in more than one such program (Banaka & Young, 1985; Witman, 1987; Witman & Preskanis, 1996).

This type of format is often used in inpatient settings, but can also be used in combination with outpatient psychotherapy.  The experiences tend to be contrived (i.e. the facility and initiatives are developed specifically for such an intervention), and focus on team games and problem-solving.  These types of activities can also be used in conjunction with high or low challenge ropes courses.

Crisp (1997) more fully defines this type of adventure-based therapy by its “emphasis on the contrived nature of the task, the artificiality of the environment and the structure and parameters of the activity being determined by the therapist.” (p.58).   In addition, he notes that the goals of the particular activities are often a specific outcome.  These outcomes are typically planned for, and influence the choosing of the activities by the therapist. 

While the activities chosen in this type of intervention may indeed be quite unique to AT, the conscious use of therapeutic technique designed to work towards a specific outcome is obviously not unique to this type of therapy. In addition, it can be noted that potentially all therapeutic situations can be thought of as contrived, again leading one to wonder how AT is unique in this way.

With regards to research design, this type of treatment has been utilized in efficacy studies of adventure-based therapy with participants from typically higher risk groups, (e.g., psychiatric populations (Banaka & Young, 1985; Witman, 1987; Witman & Preskanis, 1996)). Comparisons can be made between groups who participate in an adventure-based intervention as an adjunct to other treatment vs. those who participate in the standard treatment alone. Statements such as these are provided at this point in order to render a more integrative understanding to the informed scientific reader.  A complete discussion of  the research-based literature will follow in a later section.

 

Wilderness therapy

The second format discussed by Gass (1993) is wilderness therapy, and this type of program is most typically associated with the general term “adventure-based therapy”.  Such programs can be easily utilized as an independent treatment and are commonly seen in the efficacy literature for AT.  

In wilderness therapy, programs utilize an expedition-oriented format in remote settings and treatment traditionally lasts anywhere from 7 to 31 days, although programs also utilize alternative lengths. These programs typically follow an Outward Bound type model, and the teaching and practicing of wilderness skills is an important aspect.  Not only is the learning of these skills necessary for the client’s survival and comfort, but it is also believed that this learning provides an opportunity for clients to increase their skill base and thus their own individual level of perceived competence (i.e., self-efficacy theory).  This format also provides experiences that may have more personal and concrete consequences for the participant, i.e., basic survival needs not being met properly, as well as allowing for full and extended immersion in the experience.

The learning of such skills is thought to combine with the interpersonal learning achieved through the group interaction.   Activity outcomes are often related to patterns of behaving within the group and the reenactment of social roles seen in such a group situation.  Change is seen to emerge from interpersonal and intrapersonal insight, increases in perceived self-efficacy, and the process of the group over time. Because of the nature of the intervention, groups remain intact, thereby potentially fostering an intensification of the group experience.

One problem with these types of programs is that follow-up tends to be limited and conducted by professionals who have not been involved in the wilderness experience.  Such professionals may be unfamiliar with the client’s experience and therefore less able to build on the treatment gains experienced by the client.  From both a research and a clinical standpoint, this lack of follow-up provides significant problems when evaluating long-term treatment gains associated with this type of program (Wichman, 1991). 

 

 

Long-term residential

            The third type of therapeutic adventure program is long-term residential camping.  This format has tended to be used primarily with youth at risk and adjudicated adolescents.  Program length varies, ranging from several months to over a year.  Such programs are characterized by Buie (1996) as utilizing considerable acreage, having a permanent base camp, and temporary camp sites built by campers (typically tent-covered wood platforms).   Clients are responsible for providing for their own survival needs and, according to Gass (1993)  “the client change is seen to be associated with the development of a positive peer culture, confronting the problems associated with day-to day living, and dealing with existing natural consequences” (p. 10).  Education in traditional school subjects is also provided during such programs. 

If left without further explanation, this definition suggests that while these programs may operate in a different setting than typical non-therapeutic residential facilities for children (e.g., boarding schools), there may be no clear difference between such programs and any other type of residential atmosphere.  However, again it must be made clear that such programs have a stated therapeutic emphasis and therefore attempt to utilize some level of therapeutic processing to facilitate therapeutic growth and change.  As can be assumed, however, it is often unclear to what degree and in what way this emphasis is adhered to. 

Research designs based on both of the latter programs typically compare persons who have been involved in an adventure program with those who have been involved in some other  restricted setting for similar lengths of time, i.e., incarceration, probation or juvenile detention (Castellano & Soderstrom, 1992; Kelley & Baer; 1971; Willman & Chun, 1973).  Given the high levels of criminal involvement and societal dysfunction often found with the clientele typically referred to such programs, objective outcomes measures such as recidivism rates, academic success or employment rates have been used as a basis of comparison.

 

Group Focus

The second characteristic of AT is group focus, and AT is almost exclusively a group process.  As in many therapeutic settings groups typically range from 6 to 14 people (Kimball & Bacon, 1993) and the clients tend to be somewhat heterogeneous in terms of therapeutic issue or diagnostic category.  

As with any group psychotherapy, this group component is a vital part of the overall therapeutic aspect of the intervention. Similar to any therapy group, the group in AT provides support, feedback, and a potent interpersonal context.  Uniquely, however, in AT specific activities are presented to the group as challenges to be overcome, and success depends on each individual member participating in their completion (e.g., by standing on a platform, scaling a rock face, or negotiating unmarked terrain to a specified destination). In order to master any of the challenges, the group must cooperate, apply skills, creatively problem solve, and rely upon each other.

Herbert (1996) discusses more completely the issue of creative problem solving as it relates to AT.  He notes that each activity is concrete and has a clear beginning and a clear ending.  Problems can typically be solved in a number of ways, and there are also a number of ways that groups and individual clients tend to approach a problem unsuccessfully, thereby increasing the level of perceived difficulty of the activity.  What is expressly different about AT and other problem-solving formats is that in order for the tasks to be completed, all participants must play a role in order for the group to succeed (i.e., utilization of superordinate goals).  Therefore, activities require the group to discuss and decide on different strategies, implement such strategies, modify those that are unsuccessful, or implement new strategies; all potentially important skills for clients to practice.  Not only does this process involve the completion of the task, but group dynamics involved in the decision making process are closely followed and the interpersonal aspects of the activity are then processed by the therapist in a similar fashion as any other type of group therapy. 

Drawing from the theory of interpersonal group psychotherapy (Yalom, 1995), it is further thought that group focus leads to the intensive activation of a client’s interpersonal patterns, which, in conjunction with appropriate therapeutic processing, facilitates therapeutic change.  This assumption also echoes Yalom’s “social microcosm” theory of group functioning in which it is assumed that “patients will, over time, automatically and inevitably begin to display their maladaptive behavior in the therapy group” (Yalom, 1995, p. 28).  Therefore, this group context provides an environment for the enactment of individual pathology and the problem-solving associated with the group process may lead to further concrete representations of this, as well as provide an opportunity for the practice of new behaviors. 

Also similar to interpersonal group psychotherapy, it is not just WHAT happens during this problem-solving process but HOW it happens in the group that is of interest.  For example, how did the group decide on which strategy to use?  Who was the leader?  Did some clients participate in the decision making process more fully than others?  Is this a common response for them or a new behavior?  What was it like to work through this problem?  How did it feel?  Each of these components, along with others that can lead into deeper level therapeutic processing, provide a rich opportunity to observe and process a client’s relational processes.

Finally, it is also thought that the more active and concrete nature of the “task” in AT may lead to greater involvement for all clients than does traditional group psychotherapy.  Importantly, such higher levels of involvement have been shown to be a significant predictor of psychotherapy outcome (Gomes-Schwartz, 1978)  While these same principles operate in traditional group psychotherapy, realistically certain members in a traditional therapy group can achieve “success” regardless of the level of participation of others.  While it can recognizably be argued that a skilled group therapist in any therapy setting can involve the entire group, or in fact involve the entire group around any individuals client’s lack of participation, it may be that this type of “non-participation” with it’s impact on the group is less likely to occur in an AT setting.  Simply put, it is thought to be more difficult for a client to remain unengaged as the activities themselves necessitate participation.  There are no data, however to support such a statement.

 

Processing

Another descriptor of AT programs is that a great deal of time is spent processing the experience with clients and facilitating the transfer of learning into a client’s daily life. It must be noted again that this processing is not necessarily associated exclusively with the activities alone.  As mentioned in the introduction, the activities can be conceptualized as a catalyst for the processing which occurs before, during, and after activities, a catalyst which also  provides concrete examples of the consequences associated with individual and group actions.  It must also be noted once again that this processing is not necessarily associated exclusively with the activities; a statement made as a direct contrast to the view that any change which may occur is theoretically associated with the activities themselves. 

To engage in this processing, tools such as individual psychotherapy, group psychotherapy therapy, journal writing, individual time for reflection, modeling, self-disclosure, and metaphoric processing (Gass, 1993) may be utilized throughout the course of an AT program.  While the techniques listed above may be familiar to clinicians, the extensive use of metaphoric processing is an aspect of AT which may be fairly unique in it’s application and thus warrants further discussion

Metaphors are used with the client to link the learning and growth provided through the adventure-based experience to situations found in his or her “real- life”, thereby providing the generalization so necessary for the maintenance of any gains that may be achieved through the adventure-based intervention.  It is important to recognize that this perceived lack of relevance to realistic situations the client may encounter is one of the most commonly put forth criticisms of AT.  Advocates of AT claim that this metaphoric processing provides the necessary link between the AT experience and the “real-world”, however there is no data available as to the efficacy of such processing in generalizing treatment gains. 

When using metaphor in AT, the therapist takes on the role of conduit, actively helping the client to build such metaphors.  Adventure-based practitioners postulate that the use of metaphor helps the client to continue utilizing the learning and growth provided through the adventure experience in ongoing and  productive ways.   It is believed that through this use of metaphor, adventure-based experiences can help provide clients with concrete tools designed to help them to successfully negotiate their own personal challenges upon completion of the intervention.  Interestingly, this belief that therapy can function  to provide the mechanism for clients to continue their own change process outside of the therapeutic context mirrors cognitive therapy.  In fact, Beck and Weishar (1989) note that in cognitive therapy, “Patients are told that the a goal of therapy is for them to learn to be their own therapists.” (p. 305).

Processing in AT will be revisited in the discussion of AT facilitation occurring later in this paper.

 

Applicability to Multimodal Treatment

Another characteristic of AT is its applicability to multimodal treatment.  As aforementioned, AT can be used either as an independent intervention or as an adjunct treatment.  Importantly, the focus on group level processing in combination with the individual psychotherapy which takes place around the activities does not preclude a therapist from utilizing standard and accepted treatment orientations and practices in the therapy associated with the activities. 

 

Sequencing of activities

Fourth, in order to allow for the group to develop the skills and the level of cohesion necessary to achieve success in the activities, such activities are incrementally sequenced in difficulty.  This sequencing also provides initial successes, or “mastery tasks”, fostering feelings of capability while counteracting internal negative self-evaluations, learned helplessness, and dependency (Kimball & Bacon, 1993).  This provision of a mastery task (success) concurrent with the activation of negative self-evaluations is an important component for the therapeutic change thought to be associated with AT, as the mastery task is thought to provide an opportunity to tangibly disprove such evaluations.  It is the therapists role to facilitate such a transfer as such connections are not believed to be an automatic reaction to the activities.      

Conversely, activities presented with inappropriate sequencing can be counter-productive and reinforce negative self-conceptions for individual participants. The activation of such negative internal processes for a client without the opportunity to counteract such feelings with success can further reinforce existing beliefs in personal ineffectiveness.  In addition, such negative conceptions can also permeate the development of a group identity.  Therefore, it is vital that the therapist not create a situation in which the group repeatedly experiences failure as it can be recognized that this dynamic can carry the highest potential for emotional harm and would be likely to limit therapeutic potential.  As with other types of therapy groups, it is recognized that success is often dependent on the facilitator remaining aware of where the group is in its development (Yalom, 1995) and taking this into consideration when planning.

 

Perceived Risk

While sequencing is extremely important and requires the therapist’s clinical judgment and acumen to choose activities wisely, on the surface challenges are often structured so as to appear to be impossible or dangerous to the group. In actuality, the challenges are in fact low in actual risk but high in perceived risk, with the term “risk” referring to not only physical risk, but also intra- and interpersonal risk as well.  For example, standing on a platform and falling backwards into the arms of others requires more trust than utilizing another person’s support to cross a log.  However, at earlier points in a groups development this need to be supported (i.e., depend or rely on someone else), could be perceived as carrying as high a level of interpersonal risk, along with the associated intrapersonal risk, as any physical activity for some clients.

 Conceptually, perceived risk is thought to create tension and disequlibrium within the individual, ultimately leading him or her to a position of choice (i.e., dissonance theory).  With regard to this conviction, Herbert (1996) notes that “In order for a person to achieve equilibrium, persons are challenged to make necessary adaptations.” (1996, p. 5). He goes on to state that “Adventure-based work recognizes that it is the effort to overcome obstacles and, in effect, overcoming one’s own fears that is critical.” (p. 5).  Through this combined of process of relieving dissonance and overcoming fears, it is commonly believed in AT that clients are shown that old patterns are destructive and new choices can lead to more successful behaviors.

So central to AT is this perception of risk, that Amesberger (1998) notes “The most striking difference between adventure-based therapy and traditional psychotherapy is the client’s strong involvement in a reality that is neither harmless nor perfectly safe” (p. 29).  One could argue however, that this belief also permeates traditional psychotherapy as well.  For many clients, the deep level of emotional sharing found in a traditional therapy setting carries a high level of perceived risk, and the early sharing of basic information with a therapist may be as threatening as later sharing of seemingly much more personal information.  Therefore, it seems this difference may be much less apparent than Amesberger believes.

 

Unfamiliar Environment

Another core characteristic of AT is that it is usually conducted in an environment unfamiliar to the client. This use of an unfamiliar and novel environment is thought to unbalance the client, further activating their underlying inter- and intrapersonal processes.  It is hypothesized that the client has no familiar template from which to draw their reactions to the new situation, and thus it is the conviction of AT practitioners that the client must eventually rely on potentially new and ideally healthier ways of behaving in order to achieve success (Gass, 1993) and equilibrium.  In a sense, this can be perhaps be conceptualized as providing an opportunity for clients to be free of past determinism.

This conception appears, however, to overlook an important intermediate step.  While this unfamiliarity with the environment may ultimately result in new ways of behaving for a client, the social microcosm theory of group psychotherapy (Yalom, 1995) implies that prior to engaging in new behaviors, the client will first begin utilizing earlier learned and more dysfunctional ways of behaving.  It can be assumed that only through this activation of dysfunctional ways of behaving will more functional ways become apparent to the client. 

To link AT with the social microcosm theory, the assumption underlying the unfamiliar environment in AT theory is that by taking a person out of their normal context, the client is exposed to new situations where old patterns of coping probably will not work.  If this does result in dysfunctional behavior being evidenced first (social microcosm theory), it is possible that through the AT activities the client may be provided with more tangible evidence of the consequences of dysfunctional behavior than is typically provided in group psychotherapy.  These concrete consequences of dysfunctional behavior in combination with a novel environment, an environment which may necessitate new ways of behaving, could provide an impetus for change.  In addition, the group can also provide reinforcement for new ways of behaving.  Theoretically, this can also be seen as similar to the stimulus-control tenet of operant learning theory.

This environmental unfamiliarity in AT is also thought to allow for the client to experience the therapy not only without drawing from their standard template of behaviors, but also without drawing from their typical expectations and defenses.  Therefore, it is thought that this unfamiliarity may allow for a client to approach the therapeutic experience with less of a defensive posture.  Golins (1978) contrasts AT to traditional therapy methods on this issue of defensive posturing, noting that “traditional individual or group therapy methods may be particularly threatening for persons who have difficulty expressing themselves and/or establishing new relationships.” (cited in Herbert, 1996, p. 6).  To compare this with traditional psychotherapy research, Orlinsky and Howard (1986) have found “the dimension of the patients openness vs. defensiveness to be related to outcome”(p. 219).  If in fact AT does work to lower defenses, this finding suggests that lowered defensiveness may contribute to a more positive outcome for clients.  As with other claims of AT however, this premise is purely speculative in nature.

As with dysfunctional behaviors, it is thought in AT theory that when a client’s defenses do inevitably become activated, the therapist and the client may be provided with tangible examples through the activities and the interpersonal interactions around the activities of the ways in which defenses operate in a client’s life.  In addition, the unfamiliar and novel AT setting may then provide a situation that is less threatening for some clients to experiment with new and less defensive behavioral and relational patterns. 

While such opportunities are available in traditional settings based on interactions with the therapist or other group members, the examples and outcomes of behaviors and defenses may be more concrete for the client in the AT setting, particularly for those with a low level of insight capability.  In this sense the activities can be perhaps again be best conceptualized as the catalyst for such defensive reactions with the therapist and the group providing the medium for the activation, the recognition, and the processing of such defenses. Viewed in this way, AT parallels many of the principles of interpersonally-oriented individual and group psychotherapy.  Given this relationship, it is possible that AT may provide an alternative and potentially less threatening medium for the achievement of similar goals as group psychotherapy which may work better for some clients.  As with all of these theoretical postulations, however, this is purely suppositional as there are no data to provide support for this contention.

Finally, while it could be argued that the atmosphere of a traditional therapy session may be completely alien to one unfamiliar with the process, this unfamiliarity is realistically based on the relationship between the therapist and the client as opposed to the actual office setting.  AT settings, in contrast, are typically unfamiliar physically as well.  It is thought that these multiple levels of unfamiliarity add an additional level of novelty  to the AT experience beyond that found in the standard therapy room.  In addition, the AT setting often changes, either literally or through the choice of activities, and therefore is felt to remain somewhat more novel throughout the process than traditional psychotherapy. 

 

The Relationship between perceived  risk and environmental unfamiliarity

Herbert (1996) discusses how the unfamiliarity of the environment and the high level of perceived risk interact and how this combination is presumed to affect the client. He refers to this interaction as “challenge/stress”, and reviews how it is believed by AT proponents that the dissonance created by the unfamiliar environment, in combination with a high level of perceived risk, results in an increased intensity of the activation of interpersonal and intrapersonal processes. Herbert goes on to discuss this interaction and subsequent activation as a potential change mechanism, noting that “Stressful experiences that are likely to occur throughout an adventure based program serve as impetus for individual change” (p.5).  Gass (1993) also discusses this phenomena, referring to this type of stress as positive stress, or “eustress” 

It is this belief in client dissonance and the associated intensive activation of intra- and interpersonal processes, the unbalancing based on the lack of familiar “templates”, the opportunity for new behavioral choices, the reinforcement provided by the activities, and the associated processing that moves AT most completely away from outdoor adventure programs and into the realm of therapy. Again it should be noted that while the form this unbalancing takes may be seen differently based on theoretical orientation, this may found in any type of therapeutic setting.

Nevertheless, it is thought in the AT literature that clients who make new behavioral choices in order to complete a novel challenge they had interpreted as carrying a high level of risk, particularly one they had previously thought themselves incapable of, are thought to see themselves differently with the ultimate goal being the recognition of their own self-imposed limitations.  Through seeing themselves differently, clients gain in self- esteem, and such gains which have been linked to decreases in anxiety and depression (Gilbert, 1992).  Relatedly, Priest (1993) has suggested that participants will be able to influence their probability of success in an adventure experience if they have realistic perceptions of risk involved in the choices they make, as well as a realistic sense of their own competence. In addition, on the intrapersonal level the client is presented with concrete examples of whether their typically negative self-evaluations and self-expectations triggered through the interaction of perceived risk and environmental unfamiliarity have been proven or disproven.

 

Challenge by Choice

Related to the discussion of perceived risk is the recognition that clients are given the option of “challenge by choice”.  This allows for a client to choose not to participate in an activity with which they are not personally comfortable.  It is important to recognize that the choice to not participate in an activity is not necessarily negative and may have as many therapeutic implications as participation (i.e., choosing not to participate is still a choice). Such an instance may potentially reflect positive steps toward clients asserting their personal boundaries by recognizing and acting on personal discomfort, a potentially important issue for many clients.  In such a situation, the therapist should make every effort to include the client in some way, such as spotting or observing. According to Royce (1987), “The key to growth in any situation is that the participants should choose to confront their fear rather than being forced to engage in fearful activities.  This allows for the individual to take control of their life instead of being other-directed.” (p.28).

As one can perhaps infer from the above statement, “challenge by choice” is thought to be based not only on the recognition of risk involved in activities and related boundary issues, but also to an extent on the construct of learned helplessness (Seligman, 1975).  Groff and Datillo (1998) discuss learned helplessness theory as it relates to AT, noting that past experiences leading to attributions which result in feelings of helplessness can generalize to other areas of a persons life, potentially resulting in a decreased motivation to engage in activities of which he or she is unsure of the outcome.  As learned helplessness has also been espoused as a causal element in depression, this may be an important link to explore regarding AT’s potential for therapeutic change.

It is believed that “challenge by choice” can help lead to the recognition of the power of individual choice that can perhaps begin mitigating learned helplessness (Groff & Dattilo, 1998), thus contributing to the development of a greater sense of control for the client and more realistic cognitive attributions for events.  Should such a decrease in learned helplessness occur, it may contribute to decreases in depression levels for some clients.  While there is no evidence based on AT to support such a statement, if this proposed phenomena were to occur it seems the theory would predict that through increased recognition of alternative choices (e.g., choosing non-participation) in combination with alterations in attribution styles that may be developed through the processing of such choices, clients may develop an increased sense that their level of personal control can be related to external, specific and unstable causes, as opposed to internal, global and stable causes associated with feelings of lack of control (Comer, 1998).

Schoel et al. (1988) share this example to illustrate the power of challenge by choice: 

“A short-term patient [from the Institute of Pennsylvania Hospital], a lawyer, was very depressed, denying his problems, not involved in anything, complaining of a bad back, etc., reluctant to do anything.  He eventually tried some of the activities, and on the last day got up on a high element [ropes course] and completed it.  According to the therapist, “he felt he never would have attempted the Incline Log at all if we had pushed him.  The important thing is that we gave him the decision-making power.” (p. 132).

 

 

Provision of Concrete Consequences 

An additional descriptor of the AT approach is that the activities provide an opportunity for positive and negative concrete consequences of a client’s behavior to be readily apparent.  Beyond those aspects mentioned previously, another important aspect of this characteristic is that individual actions have consequences for both the group as a whole and the individual in relation to the group.  A client who is unable to, or chooses not to, work successfully with the group is impacting the entire groups functioning.  Therefore, he or she may find his or her place within the group altered, may miss out on the group accomplishment, or even more concretely may have a wet sleeping bag due to not setting up a tent correctly.  Conversely, clients also experience the impact of positive behavior as well within the group.  Such consequences at the group level may  provide an opportunity for important developmental learning for individual clients.

As a hypothetical example, at the start of a week-long expedition, the group leader tells participants to pack rain gear on the top of the pack.  The group leader is aware that there is potential for a rain storm during the course of the day and hopes to help the participants learn better packing skills.  “Jeff “ refuses to listen and acts in defiance of the leader, packing all of his rain gear on the bottom of the pack.  Later in the pouring rain, Jeff is forced to remove all of the other items from his pack in order to reach his rain gear.  The other gear, and Jeff himself, becomes soaked in the process.  This gear included some of the dry food that was planned for the group’s meal that evening.  Justifiably, group members become angry with Jeff and he becomes temporarily ostracized, leading to conflict in the group and consequences for Jeff as a group member.  The rainstorm also provided a natural individual consequence to Jeff for not heeding the advice of the group leader.

 

Goal Setting

Goal setting in AT involves identifying for each client the objectives of program participation, with the ultimate goal being to tie the intervention to specific psychological outcomes for clients.  Such goals are not related to the activities, rather, as with any psychotherapeutic treatment, goals are focused on specific problem areas for individual clients.  As with any therapeutic intervention, these goals are developed after consultation with the client and/or the referral source and must be held in the therapist’s awareness throughout the scope of the intervention.  In addition, group goals are also established and often a “full value contract” is decided upon, specifying the parameters of acceptable behavior within the group.  This type of contracting maintains that all participants work together as a group to achieve both individual and group goals, adhere to necessary safety guidelines, and give and receive feedback when appropriate (Schoel et al., 1988).  These guidelines are also set to promote physical and psychological safety for all participants.

 

Trust Building

            As in any therapeutic process, trust building is a crucial characteristic of AT.  Clients must learn not only to trust their therapist, but also to trust and depend on other members of the group, allowing for the closer examination of interpersonal processes related to trust as an ongoing therapeutic issue.  This is again not unique to AT but rather mirrors the theory of interpersonally oriented group psychotherapy, and most specifically relates to the stages of therapeutic group development (Yalom, 1995). 

The process of building trust is accomplished through the aforementioned sequencing of activities involving an increasing level of cooperation and group interaction. Most adventure-based therapy begins this gradual trust building process by learning basic level information about each participant, allowing for the trust building process to begin in a way that may feel more natural for clients than does traditional group psychotherapy.  As the activities progress, a higher level of self-disclosure is required and participants share deeper level experiences and emotions. As previously mentioned in the discussion of defenses, the activity focus of the group may allow an alternate medium for individuals to gradually share parts of themselves without the fear of being ridiculed or laughed at (Rohnke, 1995).  Thereby it is speculated that the activities could provide a vehicle for emotional sharing and closeness for those to whom the more direct approach found in traditional psychotherapy may be overly threatening.   

Physical trust is also incorporated and is conceptualized as a gateway to interpersonal trust (Schoel et al., 1988), with the assumption being that as clients increasingly entrust other group members with their physical safety, they will gradually begin to entrust the group with their emotional safety as well.  As overall trust increases, the group becomes more autonomous and self-reliant, as well as more willing to openly communicate.  As with a traditional therapy group, it is felt that when the group reaches this level of autonomy that it is the most powerful vehicle for lasting change (Yalom, 1995).

 

Enjoyment

            Enjoyment is also a component thought to be inherent in AT, and this is one aspect of AT that may be fairly unique.  Simply put, it is felt by supporters of AT that people are more invested in their treatment when it has positive reinforcement, and allowing for parts of therapy simply to be fun may be one way to provide an opportunity for such reinforcement.  An increased level of enjoyment may also help in increasing attention levels and is believed potentially to take some of the seriousness out of aversive topics.  As opposed to treating such topics lightly, this may be a positive step in that it might reduce a client’s reluctance to discuss such areas and allow for the discussion of such topics to be initiated more indirectly, leading ultimately to more open discussion of such often avoided topics.  This can be seen in some ways as similar to systematic desensitization, where aversive stimuli are paired with relaxation in order to decrease anxiety levels (i.e., relaxation during imaginal phobic exposure facilitates emotional processing and thus the extinction rate of the phobic response).  While this statement is lacking empirical support, in AT this type of enjoyable interaction may function similarly as does relaxation in facilitating therapeutic change.   

To create such an atmosphere, many activities in the early phases of an adventure-based intervention are designed for the sole purpose of increasing group cohesion through sharing laughter.  These activities break the ice and are thought to move the group more quickly and efficiently into the “working phases” of a group’s development.  Golins (1978) also suggests that the gamelike atmosphere of such initiatives allows for people to let down their defenses and be more willing to participate and reveal themselves.  In addition, one can speculate that clients who may process experience in a less verbally oriented manner may participate more fully in this type of intervention.  If this were the case, it would perhaps allow for greater growth among those clients for whom traditionally psychotherapy feels too threatening or invasive.  Again, however, this statement is purely conjecture, as there are no studies examining this hypothesized phenomena.

 

Peak Experience

            The final characteristic of adventure-based therapy is peak experience.  Herbert states that “the purpose of the peak experience is to provide an opportunity to practice all of the learning that has occurred and apply it to this one intensive challenge.” (1996, p.6). These experiences can consist of an actual “peak ascent” or similar wilderness experience, or can take the form of a group activity utilizing a high degree of cooperation and trust.  In both types of experiences, clients experience the challenge as more intense and complex, and these types of experiences are often used as the culmination of the group experience, giving the clients an opportunity to practice what they have learned.  Of all of the above characteristics, this is the one which may vary the most based in which type of programming format is utilized.

            While possibly being unique to the actual therapy setting, this search for a peak experience is clearly not unique theoretically to AT.  As mentioned above, the emphasis on peak experience as a part of self-actualization is a crucial underlying assumption of humanistic theory (Csikszentmihalyi, 1990; Maslow, 1971).   Maslow discuses the power for growth embedded in such peak experiences at length, noting that “in a fair number of peak experiences, there ensues what I have called the “cognition of being” (p. 173) , noting that this refers to “a technology of happiness” and the avenue to “pure joy” (p. 174).  

Again it can be seen throughout this discussion of the characteristics of AT that while AT follows parallel therapeutic principles other forms of treatment, it is clear that the belief in the power of the activities themselves and the context in which they take place is what primarily differentiates the approach.

 

Illustrative Example

To illustrate, Jane is a hypothetical 32 year-old woman who typically blames others for her problems and often uses threats to get her way.  Jane has come to therapy because she “has trouble in relationships” and her ultimate goal in therapy is to both understand and change this problem.  Imagine Jane, 30-feet up in the air on a high ropes course element.  Her heart is pumping, her fears and anxieties are increasing, and she is beginning to become frustrated because she believes that she cannot proceed.  It is likely that if Jane approaches the situation in her “standard way”, by yelling at others and blaming them for her inability to complete the task, she will remain where she is and only become more entrenched in her spiraling negativity.  This behavior will inevitably alienate members of the group, making it unlikely that they will come to her aid and support her in succeeding.

The level of risk which Jane perceives in the situation has led to an experience of disequlibrium, or feeling unbalanced, leading to Jane’s reenactment of previously dysfunctional interpersonal patterns. In this instance, with no further therapeutic intervention, Jane remains stuck on the ropes course and there is tangible evidence of the consequences for her continued maintenance of old ways of behaving.  Should she manage to simply get down off the course, she may have learned something but it is unlikely that the learning will provide lasting characterological change.   In fact, an equally likely scenario is that the intervention may be harmful for Jane by reinforcing her negative self-conceptions.  

However, if the therapist processes this experience with Jane and the group in a way that helps her to recognize her dysfunctional ways of behaving, as well as assisting her to achieve some level of control and an increased willingness to work with others, she is much more likely to complete the activity successfully. This processing may take place later in individual sessions as well.  On the group level, other members also provide Jane feedback as to the consequences of her actions, also both while such actions are occurring and after they are completed.

Should Jane succeed, such a success will ideally reinforce for Jane the new and more positive ways of behaving, as well as illustrate for her the negative aspects of behaving in her old patterns.  If the therapist the therapist were to expand this processing to an exploration of where these dysfunctional patterns originated (using a psychodynamic orientation), Jane could potentially gain insight into these origins and perhaps begin establishing more functional ways of relating to both herself and to others on a level beyond that provided by the activity alone.  Should the therapist continue his or her relationship with Jane upon her completion of the AT intervention, such concrete examples provided by the activities could perhaps be referred to as points of reference by both Jane and the therapist.  In such an instance, the process of change  beginning for Jane during the course of her AT treatment component could potentially be continued and deepened through this ongoing relationship.

What can be seen here is a direct parallel to traditional psychotherapy, with the activity itself simply providing both the catalyst and a concrete external representation of pre-existing issues for Jane.  Jane’s behavior can be explored, as well as her cognitions, affect, and interpersonal functioning.  Repetitions of the activity or participation in new activities can give Jane an opportunity to practice different ways of behaving, thinking, feeling relating, again with tangible and easily seen results. . Over time, the illustrations provided by the activity can be referenced by both Jane and her therapist.   Ideally, a skilled therapist builds upon this learning process, allowing for the activities themselves and the processing associated with them become an inextricably linked and circular process.  This type of model can be used in any of the aforementioned settings when the actives are processed in a therapeutic manner.

 

 

 

Facilitation in Adventure-Based Therapy

Facilitation found in AT programs specific to the activities themselves (i.e., aside from the group and individual psychotherapy which occurs separately), takes a somewhat unique form.  As an aside, the reader is again reminded that the individual and group psychotherapy that occurs can also be conducted using therapeutic approaches associated with any orientation. 

Gass (1995) notes that there are six different styles of facilitation for adventure-based activities, each of which results in differing levels of emotional processing for clients.  As with much of the theoretical base of AT, there is no empirical evidence supporting any advantages or disadvantages associated with any of these styles.  The above example will be utilized to illustrate each of the forms.

Gass (1995) notes that the first three styles which will be discussed are primarily characteristic of adventure/outdoor education programs, while the following three are more commonly found in adventure-based therapy programs.  In line with this contention, critical readers are likely to see limited therapeutic benefit in the first three styles, but it is important to note that they do in fact exist in some AT programs and therefore must be included in this discussion of facilitation.

 Gass (1995) believes there to be significant differences between these first three styles and the following three facilitation styles, stating that the latter styles employ proactive techniques enabling the facilitator to “enhance a client’s adventure experience and its future applications” (p. 2).  In addition, he notes that these latter styles have in common a focus on behavior change, and the belief that the experience itself and the processing of the experience is more effective at facilitating change than are analogies created after the experience (i.e., debriefing).

 

Facilitation Styles in Basic Outdoor Programs 

 

Letting the experience speak for itself

The first style is “letting the experience speak for itself”.  This approach characterizes many adventure programs where the goal of the facilitators is to provide a well-run and meaningful wilderness experience for the participant.  Personal insights and understandings are left to the client to recognize individually, and it appears as though the belief is that the inherent value in any AT experience is so powerful that such value will be clear to all participants.  The premise is that clients will “learn by doing” and that well-designed and well-sequenced activities will “lead clients to their own insights” (Gass, 1995, p. 2).  Gass notes that with this type of facilitation, clients may have a positive experience and increase their skill base, but are less likely to learn about themselves or the way in which they interact with others.  Referring to the example of Jane, a therapist utilizing this type of facilitation would have let Jane work through the experience with no further processing, assuming that necessary learning will naturally occur.  This type of facilitation seems to suggest an increased potential for emotional harm to the client.  In addition, it clearly overlooks any therapeutic benefit associated with processing.  Therefore, it seems as though this type of facilitation would be of limited therapeutic benefit.

 

Speaking for the experience

In the second style “speaking for the experience”, the facilitator aids the client in interpretation of the experience.  Examples of this may include informing the client of what they may have learned and how they can apply this to their future.  Gass (1995) notes, however, that he believes that telling clients what they have learned may be “disempowering, hamper future opportunities for growth, and alienate the facilitator from the clients.” (p. 3). In this instance, the therapist would have pointed out to Jane her dysfunctional ways of behaving and told her directly what the implications of such behavior may be.

 

Debriefing the experience

Attempts to resolve such issues have led to the third style of facilitation, “debriefing the experience”.  Gass (1995) discusses how “ownership” of personal issues can lead clients to personalizing and following through on changes they may have recognized a need for, and this method is an attempt to build on this principle. With this style of facilitation, clients are asked to actively reflect on their experience, openly discussing the learning that may have occurred for them.  This process is assisted by facilitators who design questions to help clients through this process, and has been  referred to in the AT literature as the “Outward Bound Plus” model (Bacon, 1988).  Should Jane have been working with a therapist utilizing this facilitation style, she would have been asked a series of question’s designed to highlight specific issues and situations that Jane encountered during the activity.

 

Facilitation in Adventure-Based Therapy Programs

 

Directly frontloading the experience

Moving into the more therapeutic facilitation approaches, the fourth approach, “directly frontloading the experience” is based on the belief of some practitioners that there may be some benefit in directing the client prior to beginning an activity.  The emphasis is on additional debriefing (processing/discussion) prior to the experience, a debriefing in which the facilitator typically highlights key areas.  Gass (1995) lists five topics which the facilitator may address at this point:  1) Revisiting the last activity,

objectives of the activity, 3) motivation for the activity, 4) function of specific behaviors they relate to success, and 5) dysfunctional behaviors that may hinder success.  Through this extra debriefing, the facilitator directs clients towards specific objectives that are based in the facilitators assessment of the group’s needs, helping to create a cognitive set for clients to approach the activity with in order to facilitate further change. 

            With this style of facilitation, Jane would have been told about the activity in advance, been given information on what to expect, and discussed actions that may best lead to success.  The therapist may also have connected the ropes course activity she was to be involved to prior activities Jane had engaged in during the course of her treatment.

           

Framing the experience

Gass (1995) believes the fifth approach, “Framing the experience”, to be relatively uncommon.  He describes this approach as “framing experiences isomorphically”, defining isomorphs as “parallel structures proactively introduced by the facilitator so clients can make relevant metaphoric connections to the activity.  When these connections are motivating and relevant to the client, the transfer of learning [to the clients daily life] is enhanced.” (p. 4).  When utilizing this style, prior to the activity the therapist frames the experience in a way that serves as a mirror image to the client’s daily life, making connections between the activity and the client’s present-life experiences.  Therefore, the post-activity debriefing serves primarily as a reinforcer as opposed to the vehicle for change.  During this segment of debriefing, clients discuss within the group the connections that they recognized to their daily life.  This type of processing introduces the use of metaphor, referred to early in this discourse as the primary means to connect AT activities to a client’s “real-life”, and is thought to be most effective when specific changes are sought (Gass, 1995).  

A therapist utilizing this type of style may have linked the challenge of the ropes course to other personal and psychological challenges Jane faces, allowing for greater relevance and learning associated with the connection to Jane’s life outside of treatment.

 

Indirectly frontloading the experience

The rarest of the facilitation’s styles discussed by Gass (1995) is “indirectly frontloading the experience”.  This type of facilitation involves an indirect approach to frontloading and may be most useful when facilitators are working with clients who continually re-experience and struggle with difficult issues.  Although Gass’ description of this type of style is somewhat unclear and ambiguous, it appears that what may occur with such a facilitation style is the deliberate creation of situations through the activities to highlight specific areas of dysfunction. 

In Jane’s case, the therapist may have first provided a metaphor for Jane linking the activity to her real life, but also used the activity to specifically create a situation for Jane is which she may find her areas of difficulty (i.e., interpersonal relationships), expressly highlighted.

           

As has been made clear at this point in the discussion, there are many similarities between AT and other types of therapy.  The similarities mentioned include the development of skills, an emphasis on coping and behavior regulation, a recognition of defenses, an emphasis on actualization through peak experience and self-awareness, the recognition of self-imposed limitations, realistic evaluations of negative self-conceptions, potential cognitive restructuring through changes in attributions, an emphasis on behavior change and the use of concrete consequences and reinforcement, and possible activation of internalized object representations.  In addition, the theoretical basis for AT appears to have in fact borrowed heavily from other psychological traditions.  While recognizing that the activity focus potentially differentiates AT from psychodynamic, cognitive or cognitive-behavioral, and humanistic, it has been noted in this  discussion that the clear differentiating features on the theoretical level appear to be less apparent.  The following section will focus further on delineating these similarities in order to begin exploring the mechanism of change that may exist in AT.

 

 

 

Change in Adventure-Based Therapy:  The Relationship with Traditional Therapeutic Orientations

 

Proposed Commonalties

            Within the above discussion of the characteristics of AT can be seen elements of well-established psychological theories.  To date, however, there have been no attempts to articulate the change mechanisms of AT in the language of psychological theory. The discussion now turns to connections between AT and object relations, cognitive, humanistic, and behavioral theories.  In addition, the power for change which could be associated with the unique therapeutic relationship found in AT is explored.  The reader is asked to recognize the acknowledgment that empirical research is clearly necessary in order to validate and further expand any of these ideas.  As such, it is known that these comparisons are only speculative and thus they are fairly basic at the present time.  

           

Object relations theory

There are important parallels between AT and object relations.  First, both modalities seek to modify clients’ internal representations, with object relations targeting “introjects” and AT striving for a new “template” of behavior.  Second, both argue that in “unbalancing” clients, there is an important opportunity for change.  Third, both frameworks allow for a corrective emotional experience within the context of the therapeutic relationship. Fourth, both provide the opportunity for “practicing” new modes of relating, with object relations heavily utilizing the context of therapeutic relationship itself and AT utilizing the challenges, whose interpersonal and behavioral contexts extend beyond the therapeutic relationship.

This is obviously not a simplistic process. To expand on this formulation, AT proponents claim that with no familiar template to draw from clients will have to create new ways of behaving.  This may, however, be an oversimplification.  While indeed clients may ultimately try new behaviors when their old behaviors result in negative consequences, object relations theory would predict an intermediate step in that involvement in a stressful physical and interpersonal situation, without a familiar template to draw from, would be more likely to lead clients to draw from their more primitive and potentially most maladaptive internalized representations.  Therefore, the use of the activities may in actuality result first in movement by clients towards their most well-defended and/or dysfunctional states. The resulting behavioral and emotional manifestations of this would potentially be different depending on the form of an individual’s internal representations.  Object relations theory then postulates that what is necessary for therapeutic change is corrective emotional experience.

To take the AT model an additional step, it may be however that through the combination of activities involving therapeutic goals, challenge and success, group-level processing, interpersonal interactions with both the group and the therapist, and skillful and sensitive therapeutic processing before, during, and after the activities, the client is being provided with increased opportunities for relating to others.  These increased opportunities may in actuality lead to opportunities for corrective emotional experience on multiple phenomenological levels.  Such opportunities could therefore potentially result in the creation of new internal representations.

It is also possible that the combination of behavior, cognition, and affect associated with participation in the activities could more fully engage the client in this therapeutic process, potentially resulting in any corrective emotional experience becoming more anchored for the client through the activation of multiple processes concurrently.  The ongoing activities and related therapeutic processing may then provide an opportunity to reinforce the corrective emotional experience over a more continuous period of time, thereby providing a similar opportunity for such change as is theorized to occur as in object relations based therapy.

 As opposed to the well-articulated change mechanisms that can be found in object relations however, the definitive mechanism of change found in AT is less clear.  While object relations theory may echo the AT belief that “unbalancing” is important for growth of the client, object relations discusses explicitly the power of the therapeutic relationship as the change agent.  While in object relations based therapy, this relationship provides both the “unbalancer” and the new template for interpersonal behavior and relationships, the existing AT literature does not clearly delineate the change process beyond discussing the power of new learning associated with both the activities and the group process.  Indeed, from the perspective of object relations theory it could be argued that the process of replacing such “templates”, or internalized representations, is one that must take place over an extended period of time and involve extensive processing of such representations with a therapist in order to provide the client with a corrective emotional experience and lasting therapeutic change.

While this may well be a valid criticism of the AT approach, one is urged to consider the power of combining the two approaches during the AT intervention.  As noted, one can speculate that AT activities, both with their unfamiliarity and interpersonal group dynamic, may activate dysfunctional relational patterns towards the self and others based on maladaptive internal representations.  Interestingly, however, if in fact AT does activate object-level representations, combining AT with an object relations based processing model which focuses on the relational aspects of the intervention (activities), as well as on the processing of the internalized objects associated with such relational patterns, could potentially provide a way to facilitate lasting change through AT.  Such a model could also help facilitate understanding of the  mechanism of change which may underlie AT.

To add an additional perspective to this proposed model, if it is possible that the activities do in fact activate dysfunctional relational patterns (a goal of object relations), then, as aforementioned, tangible evidence of these dysfunctional ways of behaving can be derived from the activities.  Object relations based therapists would argue, however, that this evidence is available already through the analysis of the therapeutic relationship.  However, what may be lacking in an analysis of the traditional therapeutic relationship is the opportunity to practice in a therapeutic setting new ways of behaving in interpersonal and behavioral contexts that extend beyond this relationship.  It also may be difficult in object relations based therapy, especially for more concrete clients, for them to see the evidence of their own growth and change in this context. 

AT may provide such an opportunity for more comprehensive practice, with the additional benefits of tangible consequences, group level feedback, and the opportunity for personal success and triumph.  Therefore, the combination of the two approaches may combine the best of both, potentially allowing the client an experience that reaches beyond any confines of either one.  Again, the reader is cautioned to view this as speculative in that there is no data available to support such a contention.  At the present time this is the first attempt to make such a connection.

One still logically questions however: is this AT experience enough to facilitate a shift in maladaptive internal representations, or is it necessary to supplement any proposed treatment gains with ongoing psychotherapy upon completion of the treatment?  Simply put, is the AT experience enough to provide lasting change? One challenge among the many which remain as yet unmet in the AT literature is whether it is necessary to further extend and deepen the therapeutic process upon completion of the treatment to facilitate any such change process which may occur in AT.

One proposition is to combine AT with ongoing follow-up therapy, object relations based, that could work in conjunction with the potential gains associated with the AT intervention in order to more fully process and internalize any new representations of self and others that may have begun during the AT.  Such ongoing treatment could potentially provide a more complete basis for deep level therapeutic change, possibly resulting in greater treatment efficacy and efficiency for both treatment approaches with some types of clients.  Empirical investigation, however, is necessary to explore such a possibility.

 

Cognitive therapy

AT also shares similarities with cognitive therapy.  First, both are concerned with examining distorted beliefs and attempting to replace such beliefs with different, more empirically-rooted views and assumptions .  In this sense, “cognitive restructuring” takes place in both modalities.  Second, AT provides an opportunity for practicing new ways of thinking and behaving, in line with this pattern of cognitive restructuring.  Third, by targeting self concepts, AT moves into the realm of Bandura’s (1977) “self-efficacy” theory, which argues that the internal and external information individuals receive about their abilities determines the level to which they will feel efficacious.  This cognitive conceptualization is also related to the previously mentioned construct of learned helplessness, and therefore potentially to decreases in anxiety and depression.

Clearly, there may be potential for AT activities to activate distorted beliefs and the cognitions associated with them.  One can also perhaps conceptualize the goals of AT as changing the automatic thought of “I can’t” to “I can” (Blanchard, 1992).  By examining a client’s cognitive responses to the activities and the emotions associated with such cognitions there may be a perfect opportunity to integrate principles of cognitive restructuring by linking this process to a concrete and immediate example as it occurs. In addition, AT activities could also provide an opportunity for the practice of new ways of thinking and behaving, also in line with cognitive principles.

In this sense an activity may provide a perfect example of an activating event, an associated belief, and a consequence for some clients (cognitive ABCs). Through processing the AT experience in this fashion, the therapist may be provided with a unique opportunity to immediately examine cognitive distortions, a therapeutic approach found to be effective in reducing depression (Gilbert, 1992)   As has been mentioned, in this type of instance the activity can perhaps be best thought of as the catalyst to begin such a discussion which can then be grounded in concrete experience.  It must be noted that this statement is in no way meant to imply that such opportunities are not presented in “traditional” cognitive or cognitive-behavioral therapy situations, rather this is simply being put forth to illustrate a commonality, one which might also underlie any change mechanisms in AT.  As above, this model is presented as a possibility as there is no supportive evidence for such a statement.

In addition, the activities provide an immediate opportunity for success and this success could also be processed cognitively as well.  Such successes can perhaps also be viewed through the lens of Bandura’s (1977) theory of self-efficacy.  Bandura notes that the internal and external information one gains that is linked to actual evidence regarding one’s abilities and skills is the most influential in determining feelings of self-efficacy.  Therefore, success associated with concrete AT activities may led to a greater sense of self-efficacy for clients. 

To continue on this speculative path, perhaps linking both object relations theory and cognitive theory to AT could provide an expanded semantic framework for discussing any change mechanisms in AT.  Unfortunately however, these are novel ideas that remain unexamined in the AT literature, and ideas currently lacking the support of any empirical evidence.  As such, models such as these remain simply potentially interesting and undeveloped theoretical formulations. 

 

Humanistic theory

In addition, elements of humanistic theory are embedded in AT.  As noted, the humanistic construct of peak experience (Csikszentmihalyi, 1990; Maslow, 1971) is a characteristic of AT.  Second, both modalities target overall self awareness.   Third, both frameworks are concerned with awareness of available choices, including a need for realistic appraisal of challenge versus threat. Fourth, AT’s emphasis on therapist integrity, one of its stated ethical principles, parallels the humanistic emphasis on therapist authenticity (Raskin & Rogers, 1989). Fifth, both inherently involve “presence” in experiencing (May, 1969), with a focus towards a more free type of conscious experiencing (Raskin & Rogers, 1989).  Finally, AT’s overarching context of encouraging individuals to become aware of previously unrealized potential and self-imposed limitations can be seen as the very process of self actualization.

While AT’s emphasis on self-awareness, recognition of available choices, realistic appraisals of challenge vs. threat, and peak experience have been previously noted as paralleling to the humanistic tradition, there are two additional areas meriting further discussion that are congruent with this tradition found in AT:  therapist integrity and an emphasis on being fully present in the moment or “experiencing” (Raskin & Rogers, 1989, p. 157).

The emphasis in AT on therapist integrity is actually one the stated ethical principle for AT (such principles are further discussed in a later section of this paper).  To highlight, as part of the AT ethical principle of integrity it is stated that “Professionals strive to be aware of their own belief system, values, needs, and limitations,  and the effect of these on their work and their clients.” (Gass, 1993, p. 453).  This can be seen to parallel the emphasis in humanistic psychotherapy on therapist authenticity (Raskin & Rogers, 1989). 

The stated emphasis on “experiencing” can be found through the activity focus of the intervention.  It can be hypothesized that there is potential in AT for helping clients to achieve a more fully present form of consciousness, as active participation in AT activities may lead to a greater awareness of being present in the moment.  By focusing on participation, a client may be able to partially move away from internally focused negative self- evaluations that separate a person from present focused experience, ultimately leading to participation in such activities that is freer and more complete.  The focus on the activities as opposed to self-conceptions may allow for the client to practice immediacy without such practice being the stated focus, perhaps paradoxically removing the “need” for such an internal focus on evaluation.

In addition, the activities may allow for the client to experience interpersonal relationships without such relating being the focus of the interaction.  This may also allow for the client to “practice” immediacy with less of an activation of their defensive processes. Again paradoxically, they may therefore eventually achieve the goal of immediacy without conscious awareness.  Of course, it is recognized that skillful processing would necessarily be a component in such a movement as conversely, participating in activities could also further activate such negative evaluations, effectively removing a persons further from conscious experience.

Simplistically put, by participating in activities the client may spontaneously be more immediate, more present, and be “experiencing” more without being aware of the fact. This can perhaps be thought of as the ultimate goal of immediacy. It may be then possible that through processing, this more immediate self-awareness could facilitate greater awareness of formerly denied aspects of the self, helping to facilitate what Raskin and Rogers note as a “shifting away from a rigid mode of experiencing self and world to a mode characterized by openness and flexibility.” (1989, p. 157). Through continued processing, such an increase in self-awareness could perhaps become a more central part of a client’s existence.  This movement towards such a more free type of conscious experiencing is an important general focus of humanism (Raskin & Rogers, 1989).

 

Behavior therapy

Finally, AT also utilizes tenets of behavioral therapy, specifically principles of in  vivo exposure, social learning theory, operant conditioning, and classical conditioning. 

Royce (1987) notes that “The key to growth in any situation is that the participants should choose to confront their fear” (p. 10). Herbert also discussed the confrontation of fear, stating that “Adventure-based work recognizes that it is the effort to overcome obstacles and, in effect, overcoming one’s own fears that is critical.” (1996, p. 5).  These statements reflect the essence of the behavioral method of “in vivo exposure,” in which clients extinguish phobic reactions by gradual, repeated contact with aversive stimuli. However, as an aside, it is also of note that a clinically oriented reader can also see the possibility for potentially damaging flooding to occur

 The activities in AT provide an opportunity for altering behavior patterns via the interaction of external events, reinforcement, and cognitive mediation that Bandura (1977) has articulated in his model of social learning theory.  To expand on this, the activities themselves could provide the external event and the reinforcement, while the processing can potentially alter the cognitive processes.  Therefore, an alternative behavioral explanation for any change that may occur in AT could be related to the provision of reinforcement and the potential for perceptual alterations of experience based on a shift in cognition (CBT).  In addition, the activities also provide an opportunity for unique modeling to occur. 

In addition the basic emphasis in AT on concrete consequences and reinforcement is clearly in line with principles of operant conditioning.  In addition, the importance in AT of having enjoyment associated with the activities can be seen in some ways as parallel to systematic desensitization, and thus classical conditioning. 

Again however, it must be noted that as this is the first articulated relationships between AT and behavior therapy, or in fact any of these models, there is no empirical evidence available to substantiate any such theoretical statements. 

 

The therapeutic relationship

To finalize the discussion of similarities between AT and other therapeutic orientations, as well as the change mechanisms that may be operating in AT, it would be remiss to not initiate a discussion of the therapeutic relationship and it’s potential for change in AT.  Given that the strongest predictor of outcome in psychotherapy research has been shown to be the therapeutic relationship (Orlinsky, Grawe, & Parks, 1994), it is worthwhile to consider the implications of the extended and intensive relationship that is found uniquely in the AT experience, particularly in wilderness programs that last for at least one week and beyond where the clients and the therapist/s live together in the wilderness.  Specifically, it is interesting to consider the potential effects for the client of continuous involvement with the therapist, as well as the group, that lasts for an extended period of time on a round-the clock basis.

It can be speculated that for some clients this may be immensely threatening.  For such clients this may result in their being unable to form positive relationships as their defensive reactions may become intensely activated and further entrenched, essentially making it impossible for them to engage in therapy.  However, it may be that just the opposite is true- that such intensive relationships developed on an ongoing basis with no opportunity for withdrawal may in fact facilitate the creation of more positive internal representations based on this all encompassing level of relationship.

Consider the fact that if client and therapist are together for twenty-one days on a twenty-four hour basis, this translates into 504 hours of therapeutic contact, an approximate time equivalent of ten years of weekly psychotherapy. Even excluding the hours spent sleeping, that still is roughly 330 hours of contact, an equivalent of approximately six and one-half years of weekly psychotherapy. Realistically however, while it could perhaps be argued that sleeping is not relevant contact, the reverse could also be argued- that learning to sleep in close proximity and waking up together is in fact quite relevant.

Regardless, obviously a 21-day experience with no follow-up is not the equivalent of 6 or 10 years of weekly psychotherapy.  Such a comparison of the numbers is provided merely to illustrate the potential potency of this amount of time between therapist and client spent continuously.  Given this however, it is possible that the opportunity for the development of therapeutic relationships in the different, more time intensive, and more multidimensional way provided by the AT experience may facilitate growth in clients based in this relational bond.  It also possible that there may be an effect based on this twenty-four hour contact that is inaccessible in traditional forms of psychotherapy.   Of course, one cannot overlook the fact that the reverse may also be true, and that this type of round-the-clock relationship may lessen the power of the therapeutic relationship as well. 

Without empirical data we have no scientific basis for either of these statements.  It is simply intriguing to consider the power of such relationships as change agents in a different setting than that which is typically associated with therapy.  It can be speculated that it may well be that the development of this type of relationship alone could be an active change agent in AT.  If so, it may be that case that the activities and the processing associated with AT may simply be a vehicle for the development of the relationship.  If this is the case, philosophically it then leads one to wonder if this is negative-  that if AT provides an opportunity for such relationships to develop, and such relationships alone are found to be a primary agent of change regardless of anything else associated with such relationships ( i.e., activities or therapeutic processing), does this then mean AT is therefore not therapeutically effective? 

Taking it a step further, if the opportunity for such relationship formation, recognizing that this alone may be the primary agent of change in AT, resulted in equivalent change as other equivalent forms of therapy on clinically relevant measures, does that mean AT is therapeutically ineffective because “therapy” is not being conducted?  If equivalent change is found, is it not therapy regardless of technique?  It then follows to wonder, if this were the case would it then be appropriate to utilize such an intervention style without any knowledge of therapeutic factors that may be at work beyond the relationship?  Again, as has been stated previously, such a statement is not meant as implying direct support for such a contention, this discourse is simply presented as an additional element for examination and it may be that the power of this relationship is an area worthy of further investigation.

As a brief digression, according to Castonguay (2000), when faced with this type of equivalence in therapeutic change, the decision as to what type of intervention to use becomes a matter of cost effectiveness (personal communication, March 17, 2000), or therapeutic efficiency.  Therefore if AT, regardless of the change agent, was somehow shown at some point to result in equivalent change on relevant measures as other forms of therapy, then the ultimate decision as to which form of therapy to use comes down to such financial considerations.  Returning to the matter of time equivalence, it may well be that AT is in fact more efficient.  Realistically, however, a more relevant comparison is found in inpatient treatment.  In such a comparison however, once again AT may be found to be more cost effective. 

Referring back to the discussion of AT in an object relations framework, the development of such a potentially unique relationship in AT may provide greater opportunity for corrective emotional experience to occur.  If so, such occurrences may become more firmly anchored for the client based on the fact that the relationship becomes a part of their daily existence for a period of time and thus is anchored in “real experience”. 

In addition, this type of situation may provide greater opportunity for the client to engage in more positive interpersonal relationships with others and practice such relationships in settings which are not typically part of the therapeutic environment (e.g. cooking, eating, setting up and breaking camp).  To draw specifically from interpersonal theory, such opportunities for interaction that encompass the clients overall experience (at least during the program) in its entirely, may help the client to develop more positive self-conceptions as there are greater opportunities for the self to be reflected by others in such an intensive and longer-term situation.

Related to this is the potential power of modeling (Bandura, 1986), referred to previously in the discussion of behavioral theory, that could occur in such a situation.  Such modeling can come not only from observing and imitating the therapists, but also the other clients as well.  The involvement in the activities could provides a tremendous opportunity for modeling of appropriate communication, cooperation, feedback, and help-seeking, again in what is speculated may be a less threatening format to defensive clients.  Thus, such clients may be better able to attend to and utilize such modeling.  Conversely, however, it can also be imagined how a client could be exposed to detrimental modeling in such a situation as well.  Unfortunately, ss is every portion of this proposition, this discussion of the potential power of the therapeutic relationship associated with AT is again pure conjecture at this point as this is no data available on with the process of change claimed to occur in AT.

 

The above discussion focused on the similarities of object relations, cognitive, humanistic, and behavioral theory that can be seen as potentially underlying AT, ending with a discussion of the possibility for change that can be found in the unique therapeutic relationships that may develop in AT. 

While there is no empirical support underlying such statements, it is nevertheless interesting to consider the stated benefits of group- level experience and problem-solving, activities with tangible outcomes, the unfamiliar environment, immediacy, opportunity to disprove negative self-evaluations, success and the associated increase in self-efficacy that are found in AT combined with object relations- based processing, cognitively-based processing, or a combination of both over a period of time as potentially contributing to development of a unique model for therapeutic change.  To expand further, combining these psychodynamic, cognitive, and behavioral principles with a meta-therapeutic orientation that integrates concepts of humanistic theory into the model, all of which are subsumed into the unique context of a potentially uninterrupted and continuous therapeutic relationship, could be a combination worthy of further exploration from the perspective of psychotherapy integration.

While such similarities appear to be at least possible, it continues however to be difficult to articulate what factors beyond the setting and the activity focus may differentiate AT from other type of therapy.  Nevertheless, AT theorists have attempted this task, seemingly declaring that AT is in fact notably different from other types of psychotherapy.

 

Proposed Differences

            AT theorists have proposed several ways in which they believe AT differs significantly from traditional therapeutic methods.  These proposed differences of AT include first, a focus on strength as opposed to dysfunction; second, increased opportunities to practice change; third, the opportunity for clearly recognizable results; and fourth, the opportunity for therapeutic assessment found in the activities.  As will be seen, however, these are still not clear differentiating features.

            Gass (1993) discusses several tenets of therapy utilizing adventure-based activities he believes differentiate it from traditional psychotherapy methods.  Gass feels that traditionally, psychotherapy has tended to be oriented to discussing problems and areas of poor functioning.  Therefore, he notes that through “talk therapy”, the focus is often on the areas where the client is experiencing failure.  In contrast, with adventure-based therapy he believes the general focus to be on a client’s strengths rather than on their weaknesses, with the utilization of activities allowing a concrete identification of strengths each client contributed to the completion of the task.  It appears therefore that the focus is on the process of therapy, rather than the specific content. 

In this sense, adventure-based therapy perhaps mirrors the goals of process-oriented psychotherapy.  However, once again it is not clear how this is such a striking difference.  The emphasis on strength as opposed to dysfunction appears to be a critique which may be aimed primarily at the psychoanalytic tradition, as the humanistic tradition is clearly oriented towards a strength focus.  In addition, as was noted early in this paper, these types of statements reflect a simplistic analysis of the psychotherapy process, perhaps aimed at an audience lacking in clinical training.

As a further contrast, Gass (1993) believes there to be a profound difference between “talking the talk” and ‘walking the walk”.  Proponents of AT believe that traditional “talk-oriented” psychotherapy tends to be passive and often does not allow for the client to practice those necessary changes discussed in therapy.   They feel it is likely that clients may retain dysfunctional patterns of behavior because often they merely speak of changes and there is limited opportunity to demonstrate and practice such changes in a one hour per week therapy session (Gass, 1993).  This is obviously an arguable point as clinicians of any orientation could refute any such statement with examples of clients practicing new behaviors in a therapy session.  Gass (1993) also discusses how many traditional therapists have experienced the frustration of seeing clients week after week discuss change without actually seeing any functional differences in their lives.  Aside from the therapist’s encouragement, he feels in traditional therapy that clients may receive little reinforcement for change, see few results, and thus may have little motivation to practice such changes.  Therefore, it is believed that there may be much opportunity for “talking the talk” without actually having to “walk the walk”. 

While in fact it may be true that obviously some clients show little change, this cannot be specific to traditional psychotherapy.  In addition, statements such as this blatantly overlook the potential for change espoused by the object relations perspective, a perspective which believes that the power to change comes from the therapeutic relationship itself.  Unfortunately, by making contradictory statements such as this with no empirical evidence to provide support, the field of AT is left wide open to criticism from anyone exposed to the established theories of clinical psychology.

To continue this discussion, Gass (1993) feels that adventure-based therapy is a direct contrast to the seemingly eternal focus on dysfunction with no tangible results found with other types of therapy.  He notes that with AT, clients are put in a position where they have to utilize and actively practice the changes that they have claim to have been making.  Again, these statements can be shown as being in direct opposition to the principles of object relations therapy, which makes specific note of the fact that it is the therapeutic relationship itself that provides the medium for such practice and utilization of changed patterns of behavior. 

Gass (1993) also discusses how results can be clearly recognized in AT.  As has been discussed previously, it is felt by AT practitioners that the concrete experience found in adventure-based therapy can highlight dysfunctional patterns and give the client an opportunity to directly experience the consequences of new ways of behaving.  If in fact these claims could be substantiated, it could obviously be very reinforcing for the person to make changes in order to reduce tension or needs that occur during the course of the activities. In support of this claim, Bandura (1977) has noted that learning to meet challenges successfully and accomplish desired goals can increase a client’s belief in his/her own competencies and their sense of control over relevant outcomes, which can then improve their overall mood state. 

Nevertheless, once again it must be made clear that AT is not the only type of treatment where a client can experience clear and recognizable consequences and results.  In defense of AT, however as has been noted AT activities do appear to have the unique potential for providing a fairly concrete example of consequences.  Therefore, this may be in fact one differentiating factor of AT.

A brief example may help to better illustrate the features AT supporters believe differentiate AT from other therapies.  For instance, on a wilderness trip it may be necessary that one participant help carry some weight of another participant who is ill so that all participants can make it to the resupply stop without missing a meal. How to accomplish this is something that must be negotiated and each participant must help, a seemingly simplistic but very intricate interpersonal issue.  Examining this example within the AT framework discussed by Gass (1993),  the “talk” of psychotherapy is translated into immediate action with real outcomes.  The mutual dependence and shared responsibility necessary in order to successfully meet the group’s goals of helping a sick group member and also making it to dinner is felt to make adventure-based therapy a particularly powerful vehicle for change.

Gass (1993) also discusses how he finds opportunities for therapeutic assessment embedded within the adventure experience.  Given the high degree of ambiguity inherent in the adventure-based therapy situation, it is suggested that clients project their behaviors onto the activity (Gillis & Simpson, 1998).  Thus, the therapist is presented with the unique opportunity to observe and process such behaviors. However, it can be argued that clients will do this with any type of therapeutic situation, or in fact any interpersonally oriented situation at all. 

Regarding the issue of therapeutic assessment,  Kimball and Bacon (1993) actually liken adventure-based therapy to a Rorschach test, noting that the client must interpret the situation and respond to the task.  They state that this information is indicative of a client’s “life-long behavioral patterns, dysfunctional ways of coping with stress, intellectual processes, conflicts, needs, and emotional responsiveness.”  The assumption here is that a client will approach each task and activity in a way that is consistent with their personality, and values, and motivations.  Therefore, a skilled therapist can utilize adventure-based activities in order to observe and detect personality patterns and behaviors that participants may have been unwilling or unable to reveal during traditional forms of verbal and written assessment.  In addition, Kimball and Bacon (1993)  note that adventure-based activities increase the level of non-verbal interaction, giving the therapist a more multi-dimensional and complete view of a person’s functioning.

Once again, however, elements of the social microcosm theory (Yalom, 1995) and interpersonally oriented psychodynamic theory can be seen in these statements, as both theories assume that the client will act with the therapist and group members in similar ways as they act with significant others in their life.  Therefore, this is not distinctive and this “opportunity for assessment” can be found in other orientations as well

In addition, while the latter statement involving non-verbal interaction may have some merit, clearly the other statements made by Kimball and Bacon (1993) are sweeping claims, and unfortunately statements made again with no empirical substantiation.  In addition, there is little to differentiate the underlying mechanisms of AT from other types of therapy in the above statements.  Once again, these statements fall short of capturing what is unique about the mechanisms of AT as compared to other types of therapy

It is through this type of discussion that the rudimentary, overly simplistic, and broadly generalistic foundations of the field become most apparent.  Unfortunately, it appears that the experts in the field of AT have overlooked key clinical concepts in their attempts to delineate the uniqueness of the AT process.  It seems over and again that AT is potentially more similar than different to other types of therapeutic approaches.  Furthermore, when subjected a critical analysis, many of the clinically-oriented claims espoused by AT practitioners do not withstand the scrutiny.  It is clear that continued exploration of these mechanisms of change, combined with empirical studies, is necessary before such claims can be supported.

           

To finalize this theoretical comparison, it appears that the action-oriented approach of adventure-based therapy may most closely parallel the here-and-now orientation found in several psychotherapeutic traditions (i.e., interpersonally-oriented object relations/psychodynamic, cognitive or cognitive-behavioral, humanism, and interpersonal group psychotherapy). Thus, similar to these types of psychotherapy, the here-and-now orientation of adventure-based therapy may well provide an opportunity for the therapist to access previously repressed affective material through processing the experience in the moment rather than focusing on past issues.  For well-defended and resistant clients, this more activity-focused processing may provide an additional domain in which a client may experience previously buried affective responses, perhaps with a less defensive posture. 

In addition, one important and as yet unmentioned factor of AT that does not appear to fit into any clear category is that it could be providing an additional and unique medium, via the physical, to help identify affective responses in those clients who may be unable to identify and label emotions, an important part of traditional psychotherapy as well.  Empirical examination, however, is necessary in order to support this or any of the above claims.  Additional parallels to psychotherapy traditions can be found in a discussion of ethical issues in AT.


Chapter 3

 

ETHICAL ISSUES IN ADVENTURE-BASED THERAPY

 

            One additional area of similarity between adventure-based therapy and other forms of psychotherapy is in the utilization of a set of formalized ethical principles to guide the actions and decisions of therapists.  Though similar to the APA principles, the ethical principles for adventure-based therapy must address a unique set of circumstances particular to the adventure field and such circumstances must be considered in the discussion of ethics.   

It was determined by the Therapeutic Adventure Professional Group (TAPG) of the Association for Experiential Education (AEE) that it was necessary to develop formal ethical guidelines to guide professionals affiliated with TAPG.  Through consultation with the American Psychological Association (APA), the American Association of Marriage and Family Therapists (AAMFT), and several noted experts in the field, as well as examination of the ethics code of therapeutic recreation specialists and the significant writings in this area, TAPG developed such guidelines in 1991. The complete version of these ethical standards can be found in Gass (1993).

It is of note that many of the principles are similar to those found in the APA ethical standards (1992).  As with the APA ethical standards for psychologists, members of TAPG are held accountable to this code.  However, unlike the APA code which pertains to all practicing psychologists in the US, it is only members of TAPG, as opposed to the entire profession of adventure therapists, who are actually  bound by this code.  Additionally, while the APA ethical principles require that psychologists be familiar with the code (Principle 8.01), there is no such requirement in the TAPG code. Also, at the present time TAPG unfortunately has no ethical jurisdiction over those professionals who consider themselves adventure therapists but are not TAPG members.  Similarly,  TAPG has very little power to enact consequences for individuals who engage in ethical violations.  Therefore, although the TAPG ethical code exists there is little external motivation for adventure professionals to practice the code.  Given that, the TAPG ethical principles in actuality exist primarily as an ethical guide. In contrast, the APA ethical code is enforceable, and the American Psychological Association, state psychology boards, courts, and other public bodies can use violations of this code to bring charges to bear on a practicing psychologist who may be in violation of the code.

Similar as this ethical code may be to APA principles however, it is also necessary to look beyond this code in order to fully encompass the realm of adventure-based therapy.  The use of novel situations, the element of inherent risk involved in many of the activities, and the dynamic created by multi-day trips creates a set of ethical circumstances that may be unique to adventure-based therapy.  In addition, many of the people employed in the adventure-based therapy field are trained primarily in the skills required to lead a wilderness expedition, and have minimal training in issues specific to therapeutic applications of such activities. This leads to a unique ethical situation, as many AT practitioners are not considered psychologists and thus are likely to fall outside of the jurisdiction of the APA.   As such, it is necessary for the AT field to build on the standard ethical code for therapists delineated by APA, encompassing these ethical principles while also providing ethical guidance for situations that may be unique to the AT setting.   It is these areas of differentiation  upon which I will focus this discussion, concentrating heavily on the work of Michael Gass (1993, 1995) and Jasper Hunt (1994), both noted experts in the field.  In addition, I will discuss the recommended ways for practitioners to deal with such ethical situations as they arise. 

It must be noted that the activity focus of adventure-based therapy and the potential use of multi-day trips may preclude the possibility of immediate consultation with other professionals, one strongly recommended course for therapists facing difficult ethical decisions.   In addition, ethical decisions made during the course of an activity in adventure-based therapy situations may also have implications for an entire group, as opposed to just the individual and the therapist.  As such, it is recommended by Hunt (1994) that professionals in the field thoroughly familiarize themselves with the ethical standards which follow.  In addition, Hunt recommends that professionals actively envision the ethical problems which may arise specific to the set of activities they have planned.  While the ethical standards may not provide the answers for all potential situations, being both intimately familiar with and having thought through such issues may help to provide professionals with a template from which they may draw in order to make appropriate ethical decisions should the occasion arise.  This parallels the APA’s recommendation that the development of their ethical standards “requires a personal commitment to lifelong efforts to act ethically” (APA, 1992; Introduction)

 

Informed Consent

One ethical principle, informed consent, seems to provide the simplest and most comprehensive solution to many of these ethical dilemmas faced by professionals in the field.  Jasper Hunt (1994), a noted expert in the area of adventure education/therapy and ethics, is a strong advocate of the use of informed consent.  As such, it underlies much of the discussion to follow.  Related to informed consent is the aforementioned technique of “Challenge by Choice”, a way to allow for individuals to abstain from such activities they do not feel comfortable participating in.  However, it is important to note that making an informed choice as to whether or not to participate requires having been thoroughly informed as to the nature of the activity.  

The primary mandate of the principle of informed consent for AT is that “participants be well-informed of the fees, confidentiality, benefits, risks, and responsibilities associated with these services and activities prior to participation.” (Gass, 1993, p.455).  Informed consent is considered to have been obtained from a participant after they are instructed specifically as to the risks involved in the planned activities, the postulated ratio of risk-to-benefit which can be obtained from the experience, and the ratio of risk-to-benefit as compared to alternative treatments or no treatment.  In addition, participants must be informed of the element of emotional risk that may be involved.  Often the level of emotional risk involved may be much less apparent to the client.  While similar, the APA code of informed consent also requires that psychologists use language that is reasonably understandable to participants.  Therefore, using specific jargon or theoretical terms may be inappropriate when procuring consent.  In addition, the APA recommends documentation of such informed consent. 

The complexity of informed consent with adventure-based activities becomes apparent when, as a professional, it is recognizable that it is impossible to predict all situations that may occur and obtain informed consent for all of these possible circumstances.  In line with this, it is also impossible to predict the reactions to perceived risk that participants may experience.  What may be a minimal level of perceived risk to a seasoned outdoor professional may be overwhelming risk to a neophyte participant.  Related to this, it potentially requires psychological expertise and experience to anticipate the effects of such activities on a less psychologically stable participant.

In addition, it is also difficult to inform someone of the benefits that they may receive, as these benefits may differ between participants.   Therefore, Hunt (1994) notes that informed consent is based upon possibilities as opposed to certainties.  Participants must be informed of the possible events that may occur, both positive and negative.  Participants must also be informed that other exigencies may occur of which they have not been informed.  Importantly, this uncertainty is a vital component of adventure-based therapy.  Attempting to remove all uncertainty on the part of participants negates a large potential for growth and change.  Therefore, it is important for practitioners to strive for a balance in these areas. 

Hunt (1994) recommends that professionals obtain full informed consent from participants prior to beginning the treatment, but that professionals also gain informed consent prior to commencing each specific activity.  Therefore, informed consent provides the foundation upon which professionals base difficult ethical decisions.  By having been clear with participants as to what they may experience and by receiving their informed consent, professionals can be more confident that they are acting within the realm of appropriate ethical decision-making. Specific areas in which informed consent is necessary will continue to be discussed in the context of other ethical principles.

Gass (1995) outlines seven overriding ethical principles which encompass the specific areas of the TAPG ethical code.  Of note is that these principles almost directly parallel the APA general principles in meaning as well as in wording. 

 

Competence

The first principle is that staff conduct experiences with an appropriate level of competence.  Gass states that this principle involves professionals providing services within the boundaries of such areas in which they have experience, training, education, and appropriate supervision; that professionals take actions to ensure that their work is competent; that professionals stay abreast of current knowledge within the field; that professionals participate in efforts to maintain current practice, knowledge and skills; and that professionals avoid situations where personal problems or issues may impair their work performance.  Similar to this, it is stated in the TAPG ethical code that if defined standards of competence do not yet exist for a specific area, that “professionals take all steps reasonable to ensure the competence of their work”. 

Clearly, however, this principle is somewhat vague in its interpretation. Unfortunately, given the lack of ethical enforcement, the relatively small number of accredited adventure-based therapy programs, and the ongoing debate in the field as to what competencies are required of an adventure therapist, this principle is not always adhered to in its intended form. In fact, previously mentioned research indicates that many practitioners of adventure-based therapy may be lacking in some of the skills necessary to be a competent adventure therapist (Berman, 1995).

This particular area presents a potential conundrum for a practicing psychologist who engages in or supervises adventure-based therapy.  It appears from the above mentioned survey that many persons who are practicing in the AT area may not meet the stated APA principles of competence, which states that “psychologists provide only those services and use only those techniques for which they are qualified by education, training or experience.” The ethical question is this: if the practitioners of AT, i.e., field staff, do not appear to have the essential training and qualifications to be providing psychological services, yet have experience and supervision from a professional who does, is this in line with the APA ethical standards?  Put another way, if psychological care on a round-the-clock basis is being entrusted to individuals who may not have the necessary level of training or experience to deal with psychological exigencies that may arise, is this acting in accordance with the APA ethical standards? 

One can see commonalties with a teaching situation, in which psychologists in training receive supervision from licensed psychologists, and where there is typically supervision available if an emergency arises during the session.  However, the reality of the AT situation in which those people who may in charge of providing these services may not have access to other better-trained professionals for supervision due to the nature of the setting.  In addition, these staff members are likely to not be psychologists in training and, in fact, may not have any formal training whatsoever.  In this type of situation, who is ultimately responsible?  What is the potential for psychological harm for the clients?  If services are appearing to be provided by unqualified individuals or individuals with a lack of training, is the psychologist ultimately responsible for enforcing this type of ethical principle?  This is a question that appears to be commonly overlooked by the AT field, and no specific guidelines have been delineated about the particular role of the clinical psychologist in AT.

The APA (1992) does, however, provide provisions for new practices, specifically stating that “in those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of there work and to protect patients, clients, students, research participants and others from harm.” (Principle 1.04c).  Therefore, since there are no formal standards for required competencies in AT, it would appear that the psychologist’s role is to make decisions about required staff competencies and potential for harm based on their informed judgment.  

The APA standards do address this issue specifically in standard 1.22:  Delegation to and Supervisions of Subordinates.  To summarize, this principle states that psychologists are responsible for delegating only those responsibilities that subordinates can be expected to perform competently based on their level of training, education, and experience.  This competency can also be maintained in the context of appropriate supervision.   

In addition, psychologists are also responsible for providing training in order to achieve such competency, as well as taking reasonable steps to assure that duties are actually being performed to necessary standards.   In addition, the APA standards note that psychologists are expected to correct any situations at the institutional level that are feasible to do so.  Therefore, it would appear that any psychologist practicing in the AT field has an ethical responsibility mandated by APA to make certain that all staff have the necessary level of competence to practice in ways that are in line with the accepted standards of therapeutic practice.  All psychologists in the AT field must be aware of this responsibility, and be clear on this when working with staff who may have widely diverse levels of training and experience.

As has been noted, those professionals who are not considered to be psychologists are not under the jurisdiction of APA and may not be subject to the same regulations and potential consequences,  However, when considering such ethical principles at the organizational level it may be if an organization is to be considered a provider of psychological services, they are potentially open to such ethical charges should unfortunate circumstances lead to insinuations of psychological, as well as physical, harm.  As such, it may be important for all service providers, regardless of title, to be aware of this potential area of ethical violation and take appropriate steps to ensure that staff have an adequate level of training and expertise in the provision of therapeutic services.

 

Integrity

The second principle which Gass (1995) discusses is that staff conduct experiences with integrity.  He notes that this entails conducting activities with honesty, respect and fairness, and that these principles be applied to both participants and to peers.  It includes making no false statements, and also knowing how one’s own personal beliefs and values may impact both their work and their participants. APA (1992) adds a caution about statements that may potentially be misleading as well.    Hunt (1994), discusses several of the specifics which may fall under this broad category including the use of deception and secrecy as educational/therapeutic tools . APA also addresses the issue of deception, noting that it is unethical for psychologists to make deceptive, false or misleading statements about their credentials, expertise, training, fees, research, professional affiliations, or services (principle 3.03).

Hunt (1994) notes that secrecy is different from deception, in that “deception is an act that is specifically designed to get people to believe that what is false is true, while a secretive act is simply the withholding of information and not the distortion of information.  Deception is active by nature and secrecy is passive by nature.” (p. 61).

Given the more active nature of deception, he believes that deception can result in a significant loss of trust between therapist and client, and feels strongly that this trust can be difficult to restore.  An example he puts forth involves students/clients who had been involved in learning wilderness first aid.  The group had been somewhat uncooperative and not taking the lessons seriously.  In order to illustrate the importance of the lesson, one of the instructors hid in the woods and feigned a serious injury.  In order to deal with the “injury”, the participants had to utilize their first aid training.  After several minutes of providing care, the group realized that they had been deceived.  One member of the group was extremely angry at the deception, however, the importance of the first aid training was clearly emphasized to the group.  As such, the intentions of the instructors were realized, but not without cost for the group.  Therefore, Hunt (1994) raises the question of positive vs. negative outcome.  Is it acceptable to use deception in order to obtain positive educational/therapeutic aims?  Is it OK to deceive when the outcome is positive?  How can such a positive outcome be defined when the deception itself causes a negative outcome?

APA (1992) has addressed this problem as it pertains to research.  While obviously not pertaining specifically to a therapeutic situation, these principles seem to provide the best formalized guidance available in situations where deception is deemed necessary.  Principal 6.15a states that “Psychologists do not conduct a study involving deception unless they have determined that the use if deceptive techniques is justified by the studies prospective scientific, educational, or applied value and that equally effective alternative procedures that did not use deception are not feasible.”    APA also notes in 6.15c that “Any other deception that is an integral feature of the design and conduct of an experiment must be explained to participants as early as is feasible….”.  According to these principles, a psychologist in the above situation must make a decision that such deception was clearly warranted and beneficial, and was also the best possible alternative available.   In addition, is required that they inform the clients as soon as it is possible as to the nature and the rationale of the deception.

The solution proposed by Hunt (1994) to such questions is informed consent.  He believes that the violation of trust is significantly less when participants know they may be deceived and have, in that sense, agreed to the deception prior to its use. Hunt also notes, however, that there are difficulties associated with this, namely the potential loss of power involved when participants know such circumstances as above may not be real.  The recognition that they may at any time be experiencing deception lends itself to less than full immersion in the experience, thereby potentially minimizing the impact. As a final issue, Hunt emphasizes that deception must always be used with positive intentionality, and never for reasons of power or harm.

Hunt (1994) believes the use of secrecy to also be an ethical issue, but one with potentially less damaging consequences to the relationship between professional and participant.  Hunt notes that when the withholding of information is used as a teaching tool, designed to “remove the state of ignorance in which the student [participant] already exists.” (p. 65), it results in less loss of trust than does deception (i.e., the instructor is not creating the deception, the state already exists).  As with deception Hunt notes, however, it is particularly important that the use of secrecy must only be used for the achievement of a potentially positive end.  APA provides no guidance for the use of such secrecy in a therapeutic situation. 

Specific examples of the use of secrecy discussed by Hunt include one in which the instructor is encouraging a participant to attempt a climb, a climb which the instructor knows he/she is incapable of, in order to utilize the learning which may occur under such circumstances.  A second example involves a situation in which a participant shares information with the instructor and then asks the instructor to keep such information secret.  Such a circumstance may seems straightforward enough, however, imagine that participant is asking the instructor to keep secret information that the instructor knows could endanger the participant or others in the group?  Does such a situation warrant the violation of secrecy?

As with deception, Hunt (1994) believes that the solution to difficulties created by secrecy involves the use of informed consent.  He believes that if participants are forewarned that secrecy may be used to facilitate growth, it becomes less of an issue.  Also related, he notes that if participants are informed that secrecy between instructors and participants will be maintained unless to do so may lead to harm for the participant or others, they can then make an informed choice whether or not to share such information.

 

 

Responsibility

The third principle outlined by Gass (1995) is that staff conduct experiences in a responsible manner.  To expand on this, he notes that professionals must uphold the ethical principles of their work. Specifically, Gass notes that the following are necessary: being clear with participants as to what the roles and obligations as a professional are in each situation, adapting the methods of treatment to the needs of different populations, possessing adequate knowledge and experience to make appropriate professional judgments, not initiating services with participants if limited contact will be a significant issue, and also conducting services with minimal impact to the environment.  While almost identical to the APA principle of the same name, the APA includes a statement that psychologists “accept appropriate responsibility for their own behavior.”  It is unclear why this has been overlooked in the TAPG principles.

Hunt (1994) discusses the unique AT aspect of environmental impact, raising the question of when should concern for the environment outweigh concern for individuals? (It is important to note that the “do no harm” principle is assumed to override this at all times).  He discusses how at times it can be a “conflict of values”, and feels it is important that professionals be able to adequately conduct a cost-benefit analysis in each situation that may arise.  In addition, he believes that it is important for professionals to decide where they stand personally on environmental issues, being aware beforehand what values they may be willing to compromise on.  One suggested avenue for this exploration may be that staff members discuss ethical issues as a team both prior to an activity or course, as well as debriefing at the conclusion.

For example, Hunt (1994) discusses an instance of instructors working in the wilderness with disabled persons.  One such person, a paraplegic, has lost bladder control during the course of the day and wishes to clean himself off in a nearby stream.  The question specific to this situation is this:  is it acceptable for you as an instructor to compromise minimal impact values in order to help meet this individuals personal needs?   Hunt outlines two potentialities for instructors who may be involved in such situations:  1) inform a group beforehand that there will be no compromising on environmental minimal impact values, regardless of the circumstances, and 2) inform participants beforehand that attempts will be made to maintain the dignity of the participants, even if it involves compromising minimal impact standards.  It may be desirable for participants to sign a contract making explicit what the stated policies are as a means of gaining active support for such policies.  Therefore, the principles of informed consent are once more in operation.  Participants who view the stated policy as unacceptable may choose not to participate.

 

Respect

Gass’ (1995) fourth principle is that staff conduct experiences with respect for the rights and dignity of participants.  Gass includes under this principle the right to privacy, confidentiality and self-determination, sensitivity to cultural and sexual orientation issues, and the recognition of individual differences. The APA principle D parallels this almost directly. Differently, however, Gass also includes basic informed consent and the accurate representation of professional competencies in this area.

Related to this, Hunt (1994) discusses the particular ethical dilemmas created for professional working with “captive populations”, defined as “any person who is participating in a program because of being ordered or coerced to do so, rather than through their own free initiative”. (p.71).  He notes that research increasingly shows adventure-based therapy to be a viable treatment option for these types of populations, and thus justification for the use of such activities becomes stronger.  Arguably this may not, however, actually be the case at the current time.   This will be further discussed in later portions of this paper. 

 The important question Hunt (1994) raises, however, is this:  Is it possible for a person who is not autonomous or free to give informed consent?  Hunt believes the solution to this lies in the evaluation of the possible alternative choices.  If the consequences of participation are either so negative or so positive that there really is no actual choice involved, then Hunt does not believe that this is truly a free-choice situation.  Ideally, Hunt advocates giving captive individuals a choice of participation, but providing  reasonable alternatives.  An individual may be required by law to participate in the program, but may choose to not participate in an activity.   Therefore, it is necessary to provide viable alternatives.  The creation of such alternatives which meet the stated goals of the program can require considerable expertise on the part of the facilitator.  Importantly, however, choosing to not participate is thought to carry considerable value as a therapeutic issues and should be treated as such (See Challenge by Choice principles). 

Hunt (1994) raises similar issues when considering times a participant may be an “activity captive”,  times when it is very difficult to leave an activity once the activity had begun.  For example, once a person has committed themselves to begin rock climbing, it is impossible for them to leave the activity without having to belay off the rock.  Once again, Hunt advocates informed consent for each activity in order to allow greater freedom in participant choice.

 

Concern for Well-Being

Principle five is staff are concerned for the well-being of participants (Gass, 1995). Simply put, this principle states that professionals be sensitive to participants needs and well-being, as well as providing for the physical needs of participants and monitoring the appropriate use of risk.  In addition, it is noted that professionals must provide appropriate referral when necessary and to plan experiences in the best interest of the participants. This is also a parallel to the APA ethical principle E:  Concern for Others Welfare, with an adaptation made to encompass the unique aspects of AT based on the setting and the different activity base.  Gass’ (1995) formulation is expanded upon in the TAPG ethical code, stating that “participants will be provided with the necessary food, water, shelter and other essential needs suited to the environment in which they are living in, unless there is prior mutual consent that this will serve a valid purpose ”.  The code also states that “At no time shall the withholding of these needs be used as a punishment.”

Hunt (1994)  discusses several potentially unique issues to AT which fall under this principle, including risk-benefit analysis, individual vs. group benefit, and paternalism.  Risk-benefit analysis is the ethical principle most specific to adventure-based therapy.  There is no parallel within traditional therapies which raises similar issues.  Specifically, the TAPG code states that “the amount of actual physical and emotional risk participants experience in adventure activities will be appropriate to the objectives and competence level of the participants.  Professionals will use appropriate judgment when choosing activities that expose participants to actual or perceived physical or emotional risk.” Related to this, the code also states that “professionals have an adequate basis for their professional judgments and actions that is derived from professional knowledge.”  Once again, this is a rather vague principle as the use of “appropriate judgment” is very difficult to objectively define. 

Hunt (1994) notes that there are significant difference between objective risk and subjective risk, and that a professional must be aware that both are inherent in many activities.  Subjective risk is defined as perceived element of risk that a client feels, and may take the form of interpersonal, emotional, or physical risk.  Importantly, it is this element of subjective risk which creates the disequlibrium necessary for the facilitation of therapeutic change.  However, it is difficult to estimate subjective risk as participants may perceive this level differently- what is risky to one participant may not be perceived as risky to another. Therefore, the instructor has a vital responsibility to make informed and knowledgeable judgments, judgments guided by experience, as to the level of subjective risk which participants will experience.

Objective risk on the other hand, is the element of risk inherent in activities based on the environment in which they are conducted, including the aspects of nature which are beyond human control.  For example, a person who is rock climbing may be securely fastened into a harness and wearing a very expensive and effective helmet.  During the course of a climb, however, a rock could potentially become dislodged and fall on him or her, causing injury, or a snake lurking between the rocks may become disturbed and bite the participant.  Neither of these could have been foreseen, and it is these types of risks which are inherent in an activity.  It is important to note, however, that this risk is not to be confused with any risk based on instructor error or poor decision-making.  It is a key assumption in this type of situation that everything objectively possible is done to prevent harm of this type. As with subjective risk, instructors are responsible for making knowledgeable decisions as to what is an appropriate of objective risk, as well as adhering to standard operating procedures required for each activity.  Adhering to such procedures helps to inform decision-making by instructors that may be necessary while in the field.

Hunt (1994) recommends that professionals clearly evaluate the level of risk, both objective and subjective, involved in an activity and proceed with a cost-benefit analysis.  He notes that it is crucial that instructors be aware of all levels of risk involved.  If one activity has a higher level of risk that another, is there an increased benefit as well?  Is the present environment such that it can safely support activities which carry increased risk?  If added benefits do not exceed the added level of risk, Hunt recommends that the less risky activity be chosen.  He also recommends that instructors always hold the goals of the group in mind when deciding on appropriate risks.  The goals of a group who simply wishes to participate in adventure activities for fun as compared to those who desire personal growth as compared to those of a therapy group are significantly different.  Moving the growth-oriented group into the realm of therapy introduces an unnecessary level of emotional risk and is to be avoided.  Finally, Hunt recommends that instructors remain aware that they may be held accountable for explaining why an activity with a higher level of risk was chosen.  In remaining cognizant of this fact, professionals must be able to clearly understand and be able to articulate the added benefits which come from an increased level of risk.  Clearly, this is a subjective process, and one which is open to a wide range of variability.

Related to risk levels, instructors must also make ethical decisions at times regarding whether an activity may be more or less positive for the individual vs. the group.  There are times during the course of activities when, for example, one person may not be able to complete the activity.  Other examples of this may include situations in which a participant may be violent, abusive, or for a variety of potential reasons is requiring an excessive amount of staff energy at the expense of other participants. Hunt (1994) raises the questions of whether or not the group should proceed without the individual.  Could the individual receive benefit from not participating in the activity?  Is it possible to frame non-participation in a way that facilitates growth?  Should the group be responsible for making sure that all members successfully complete an activity?  What if the individual is adamant that they be able to participate in the activity, but the instructor feels that this may jeopardize the success of the entire group? 

Through processing this dilemma, the group may reach its own solution to such difficulties, and thus processing is one choice open to instructors in such a situation. However, Hunt cautions that there are times when processing the issue will not ultimately solve the problem and the instructor must make a decision between the individual benefit or the group benefit. 

Hunt (1994) offers no clear solutions to this problem, but rather explores the rationale behind each choice.  One possibility is to consider the overall level of benefit--by allowing the group to proceed without the individual, is there increased benefit to more people?  Conversely, by allowing the individual to participate, will this person as an individual receive a greater level of good, regardless of outcome, than would the group succeeding without this individual?  Will the group achieve greater good and learn compassion and sacrifice if the individual is encouraged to participate?  Hunt also considers the question of fairness.  Is it fair to not allow an individual to participate for whatever reason, even is the possibility of success is minimal?  Is it fair to the group to hinder their possibility of success?  Are there institutional rules governing these situations?  Can rules possibly made which provide solutions to all situations which may arise?

One solution espoused by Hunt (1994) involves clearly knowing what the goals of the program are.  Therefore, it is important to know whether the activities are a means or an end.  If the activities are to serve as a means, the activities themselves are simply vehicles to reach other goals.  If an activity is thought of as an end in itself however, then the doing of the activity, and therefore the completion of the activity, is the ultimate goal.  He notes that knowing which of these is primary will influence your ethical decisions-making.  Additionally, as with the above risk-benefit analysis, Hunt recommends that professionals be aware of the ethical standards from which they are drawing and be prepared to offer rational arguments in support of their judgments.  Again, the overriding principle must be “do no harm” and a psychologist bound by both APA principles and TAPG principles must be aware of these overriding ethical responsibilities and not lose sight of the ethical obligation one has to above all do no harm to participants.  Decisions about group vs. individual benefit must be made in such a context, and solutions must provide the maximum benefit to all participants while bringing harm to none.

            Finally, the issue of paternalism also falls under principle number five.  Paternalism refers to when “an action is taken towards another person without his/her permission and justified by the action’s serving the welfare, interest, and/or needs of that person”. (Hunt, 1994, p. 129).  For example, suppose a participant, of legal age and self-referred, believes they are receiving no benefit from a 10- day wilderness experience and feels he/she wishes to hike out and return home.  The instructor believes that, in fact, the participant is receiving a significant benefit from the experience, but is unable to see this benefit clearly at the present time.  Does the instructor have the right to attempt to force the participant to stay with the group? 

Hunt (1994) lays forth five guidelines for paternalism taken from medical ethics (Vanderpool & Weiss, cited in Hunt, 1994): 1)  paternalistic actions are taken toward the participant without their knowledge or their permission, 2) actions are justified for the benefit or the good of others, 3) the Doctor is benevolent and will perform only those actions which are likely to provide more benefit than harm, 4) those who undertake paternalistic acts without consent feel qualified to act on a persons behalf, and 5) the paternalistic acts are undertaken after obtaining as accurate of an assessment of outcomes or consequences as is possible.  Hunt believes that it in order to make such decisions, professionals must determine whether or not the paternalistic acts are taking place within the context of these five guidelines.  In addition, he recommends that it is up to the practitioner’s informed judgment to know what is truly in the best interest of the participant.  As with previous ethical dilemmas, Hunt recommends that professionals utilize full informed consent prior to commencing the activities in order to best avoid such situations.

 

 

Social Responsibility

            The sixth principle delineated by Gass (1995) is that staff recognize their level of social responsibility.    As such, professionals need to remain aware of their responsibility to community and society along with respecting property and developing appropriate agency policies.  This parallels the APA principle F:  Social Responsibility, while deleting the additional APA mandate of a psychologist making public their knowledge psychology to contribute to increased human welfare.  Including this mandate within this principle would increase the responsibility of psychologists using AT to provide a solid empirical rationale for the use of this treatment. 

Hunt (1994) cautions professionals in the field to continually remain aware of the fact that they operate within the realm of a larger social context and are not isolated from social issues.  He raises the specific question of whether professionals have the right and responsibility to choose whether to provide services to groups or individuals who do not share the same social commitment (e.g., supremacist groups or groups who do not share environmentally based ethics).    Hunt once again refers to knowing the goals of the programs as one solution, determining beforehand whether such social issues are a influential factor in the policies of the program.  As a blanket statement, he cautions professionals to remain aware of the social implications of their work and their actions, warning that this may be an area in which to proceed with caution, as the implications for actions done in the AT context may extend beyond the setting.

 

 

 

Dual Relationships

            The final principle discussed by Gass (1995) is that staff avoid dual relationships with participants that impair professional judgment. This involves the avoidance of exploitation or the misleading of participants, as well as intentionally avoiding dual relationships that may impair judgment.  Gass notes possible examples of these types of relationships, including business or professional relationships, sexual relationships and inappropriate physical contact within the context of an activity.  The APA devotes several specific ethical standards particular to these important issues, namely 1.17:  Multiple Relationships, 1.19:  Exploitive Relationships, 1.13:  Personal Problems and Conflicts, 1.15:  Misuse of Psychologists Influence, and standards 4.05-4.07, principles involving the restrictions involved with engaging in sexual activity with current or former clients and therapy with former sexual partners.  

Hunt (1994) discusses this as well, focusing more specifically on issues regarding sexual contact.  As with APA guidelines, contact between a therapist and a participant is prohibited and the TAPG code states that “sexual intimacy is prohibited during the time of the professional relationship.  Professionals engaging in sexual intimacy with past participants bear the burden of proving that no exploitation is occurring.” (Gass, 1993).  The APA code is more specific to this issue, stating specific time limits of waiting least two years beyond the termination of the therapy before engaging in sexual activities, and retaining the continued responsibility to prove a lack of exploitation beyond the two year limit.   Psychologists must remain aware that they are bound to the more restrictive APA code with regards to this issue. 

In this instance of sexual activity between therapist and client, there is a clear boundary.  However, given the instance of multi-day trips, as well as the high level of interaction involved in such activities, sexual situations between participants can and do arise.  Such situations may arise not only between participants, but also between two instructors or therapists as well.  According to Hunt, any type of sexual activity has the potential to greatly affect the overall functioning of the group.  He notes clearly that he believes it to be rare that any type of sexual intimacy can occur between members of the group, including between the instructors, and not have an impact on the group.

One solution to this problem discussed by Hunt (1994) which he feels is overused is denial: by denying that any type of sexual energy will be present one can assume that it is not.  Hunt believes, however, that simple prohibition of sexuality is like denial and will not work.  By denying the presence of sexual energy or activity, the presence of such phenomena is likely to have an even greater impact on the group.  

A therapist has the responsibility to prevent harm to the group, and must make decisions based on the premise that there may be possible detrimental effects on the group if members are engaging in such activity.  However, conversely, Hunt (1994) discusses certain instances where potentially the effects on the group may be positive.  If we are speaking of contact between participants, and we are assuming legal age, what if the sexual relationship has contributed to the better overall functioning of the participants and therefore contributes more positively to the group as a whole?  Should such contact be prohibited?  The same principles may hold true for sexual relationship between instructors.  Clearly, if such a relationship has a negative impact it must be prohibited, but if the outcome is positive the answer is much less clear.  It is important to note, however, that in reality such a situation is much more likely to be damaging to group dynamics. 

Hunt (1994)  promotes two solutions to such issues.  The first falls, once again, into the realm of informed consent.  By deciding upon the rules beforehand and making those rules clear to participants, instructors are able to make decisions which are more clear cut.   Depending on a multitude of different variables, the rules may vary from group to group.  However, through informed consent the guidelines will have been made as clear as is possible.   Should, however, a situation arise which has not been made clear, Hunt recommends that professionals think critically beforehand about what the implications of sexual relationships are.  In addition, the anticipation of situations which may arise beforehand between clients is also an effective way to prepare for such exigencies.

As has been discussed, adventure activities carry with them a unique set of situational variables. Also, as has been noted, the ethical principles are somewhat vague and open to interpretation, perhaps necessarily in order to allow for flexibility in programming.  Many ethical difficulties are situation specific and therefore it is impossible in this discussion to address each type of ethical situation which may occur.  Similarly, it is also very difficult to rely on standardized solutions to guide all ethical decisions. Therefore, it is difficult, if not impossible, to provide an ethical code to apply to every potential situation. Given that uncertainty, Schoel, Prouty, and Radcliffe (1988) recommend that each adventure therapist develop their own personalized ethical code, noting that “the most accurate measure of professionalism is the design and development of a personalized code of conduct” (p. 45).  Although this statement was written prior to the formalized development of the TAPG code in 1991, it still appears to hold true as a meta-principle in the area of ethical decision-making. Given the ambiguity and  unpredictability inherent in the use of adventure-based activities as a therapeutic modality, this powerful statement remains at the core of what is essential in guiding the ethical decisions of present day adventure therapists.

Practicing psychologists using AT treatments and bound by the APA ethical standards carry the dual responsibility of being held accountable to both the TAPG ethical code and the APA ethical code.  While the APA code covers more specifics regarding the general roles of psychologists, the TAPG code carries with it more specifics related to AT.   Therefore, psychologists in this area must be familiar with both and be prepared to act ethically at all times, as well as provide supervision in this area to those who may not be held accountable to both bodies.  In this way, psychologists are in a unique position to serve the AT community and potentially contribute to an overall increase in the effectiveness of this type of treatment.


Chapter 4

 

ADVENTURE-BASED THERAPY OUTCOME RESEARCH

 

            The following discussion will be devoted to a review and detailed methodological critique of the outcome-based literature on AT.  This will begin with a discussion of the evaluation required before a treatment can receive the designation of empirically supported (EST).  The discussion will then turn to a review of three meta-analyses, moving into a focus on outcome literature with adult populations, outcome literature with adolescent populations, and outcome as it relates to client characteristics.  

 

Evaluation Criteria for Empirically Supported Treatments (ESTs)

 

Adventure therapy has been used with many different populations (e.g., court ordered juvenile delinquents, the mentally ill, PTSD sufferers, the disabled, substance abusers, eating disordered individuals, sexual abuse survivors, as well as normal populations), and it proponents claim it to be an efficacious treatment.  In reality, however, the literature shows a range of discrepant findings.  One potential explanation for discrepant findings among the existing research is the wide range of methodologies employed and the clear lack of scientific rigor with which many studies were conducted.  Thus, the conclusions and insights which can be gained are limited. As will be seen, there have been a number of studies which suffer from severe methodological difficulties, therefore effectively rendering them scientifically useless in the evaluation of adventure-based therapy. 

Gillis (1992) discusses common methodological errors found in the adventure-based therapy research, errors occurring at the most basic level of research design.  Such fundamental design considerations as equivalent control groups, randomization, psychometrically sound outcome measures, clearly defined methodologies, appropriate statistical procedures, and follow-up are often overlooked.  He also notes that many studies utilize quasi-experimental designs and thus the results have limited generalizability. In addition, both settings and treatment methods are diverse, which also limits the generalizability of results (Kelley, 1993).  Unfortunately, as noted earlier there is no clear method of conducting adventure-based therapy (Gillis, 1992) and it seems this confusion may be reflected in the research.

With the 1995 publication of the APA Division 12 Task Force on Promotion and Dissemination of Psychological Procedures came an increased awareness of the necessity for specific psychotherapeutic treatments to establish proven efficacy.  The psychological community responded to this call for empirical validation, and a list of empirically supported treatments emerged.  This list continues to grow in length (Dobson & Craig, 1998).  

Guidelines have been established for determining whether or not a treatment has received the empirical validation necessary to support claims of efficacy.  Chambless and Hollon (1998) provide a specific structure designed to guide this evaluation, defining empirically supported treatments (ESTs) as “clearly specified psychological treatments shown to be efficacious in controlled research with a delineated population.” (p. 7).  In addition they ask researchers to “consider the following broad issues about ESTs in their area:

a)     Has the treatment been shown to be beneficial in controlled

research?           

b)     Is the treatment useful in applied setting and, if so, with what patients and under what circumstances?

c)     Is the treatment efficient in the sense of being cost-effective relative to other alternative interventions?”  (p.7).

 

They note that researchers can answer such questions by performing evaluations of treatment efficacy (which includes clinical significance), effectiveness (i.e., clinical utility), and efficiency (i.e., cost effectiveness) (Chambless & Hollon, 1998).

            Chambless and Hollon (1998) also provide specific criteria necessary to be met in order for a treatment to receive the designation of EST.  While such criteria have been published elsewhere (Crits-Cristoph, 1998) and are discussed in detail by Chambless and Hollon (1998) , they will be listed here to provide background context for the discussion of the research specific to adventure-based therapy.  The criteria are as follows:

1)     “Comparisons with a no-treatment control-group, alternative treatment group of placebo (a) in a randomized clinical trial, controlled single case experiment, or equivalent time samples design and (b) in which the EST is statistically significantly superior to no treatment, placebo, or alternative treatments in which the EST is equivalent to a treatment already established in efficacy and power is sufficient to detect moderate differences.

2)     These studies must have been conducted with (a) a treatment manual or its logical equivalent; (b) a population treated for specified problems, for whom inclusion criteria have been delineated in a reliable, valid manner; (c) reliable and valid outcome assessment measures which tap at minimum problems targeted for change; and (d) appropriate data analysis.

3)     For a designation of efficacious, the superiority of the EST must have been shown in at least 2 independent research settings (sample size of three or more in the case of single-case experiments).  If there is conflicting evidence, the preponderance of the well-controlled data must support the ESTs efficacy.

4)     For a designation of possibly efficacious, one study with similar characteristics as above suffices in the absence of conflicting evidence.

5)     For a designation of efficacious and specific, the EST must have been shown to be statistically superior in at least 2 research settings.  If there is conflicting evidence, the preponderance of the well-controlled data must support the ESTs efficacy and specificity.” (Chambless & Hollon, 1998).

 

           

While solid research design is assumed in this listing, Borkovec (1994) discusses in more detail additional important aspects of design which are relevant to a critique of any treatment, specifically client considerations, therapist considerations, and dependent variable considerations.  Such aspects will be discussed further in the next chapter.  Importantly, as will be seen in the following review, much of the AT research contains flaws such that criterion specific to all psychotherapy research are threatened, deficient, or as yet have not been considered. 

 

 Meta-Analyses

 

            In order to consolidate the work of numerous researchers utilizing varying methodologies and diverse diagnostic categories, there have been three meta-analyses conducted in the overall area of adventure programming.  While none of these analyses were conducted exclusively in the area of AT (AT program results were often collapsed with other outdoor adventure programs), a review of these findings may shed light on important AT-related methodological issues.  However, it is logical to wonder why these meta-analytic reviews appear to involve minimal overlap with the body of literature which is reviewed following a discussion of the meta-analyses. 

There appear to be several reasons for this lack of overlap.  Cason & Gillis (1994) do not include in their list of references those studies reviewed in the meta-analysis, including only citations from their preliminary introduction.  Therefore, any overlap cannot be determined.  Han’s (1997) analysis focused specifically on adventure programming and locus of control.  Thus, such studies were not included in the analysis which follows of the outcome research evaluating the efficacy of AT as a treatment modality.  Hattie, Marsh, Neill, and Richards (1997) review focused specifically on studies with Outward Bound programs.  As previously noted, while utilizing similar formats, Outward Bound does not expressly pursue therapeutic goals in their programs.  Thus, outcomes studied from Outward Bound programs have only limited relevance to a therapeutic context.  [Note-those studies reviewed in the following sections which examine outcome in Outward Bound programming are included in the review as they are the best of what research is presently available].  While Hattie et al.’s study does contain an element of overlap, those studies that do overlap are reviewed separately due to questions of validity in Hattie et al.’s analysis.  Furthermore, many of the studies reviewed in the meta-analyses are unpublished.  Finally, all focus generally on outdoor adventure programming instead of specifically on AT, subsuming AT into this broad category. 

             

Cason and Gillis

Cason & Gillis (1994) conducted the first meta-analysis, examining the adventure programming literature with adolescents.  While suffering from serious methodological concerns, this study is commonly cited as supportive evidence for the efficacy of AT with adolescents and thus warrants close scrutiny.  In this first attempt at consolidation, Cason and Gillis (1994) examined all of the available literature on adventure programming with adolescents.  They reviewed 79 published studies were reviewed and out of these 36 were excluded for lack of sufficient statistical information, a non-empirical basis, or utilization of a sample not of the appropriate age. Unique “researcher-designed” outcome measures were also excluded from the analysis, as were outcome measures used less than five times due to difficulties interpreting average effect size of such a small group.  Such detail is included to provide the reader with insight into the methodological inadequacies of the literature.

Ultimately, 43 published studies were reviewed and effect sizes examined based on 19 outcome measures and 11,238 adolescent participants.  Quality of studies was ranked by Cason and Gillis (1994) on a scale of 1-6. This rating consisted of a composite score based on utilization of random assignment, timing of measurement (i.e., pre, post and/or follow-up), employment of a control group and if so, whether this group was included in any follow-up.  Studies receiving a ranking of one were noted as “requiring only pre-and posttesting without a control group” and those receiving a ranking of six employing “a control group with random assignment and pre-post and follow-up testing for both experimental and control groups” (Cason & Gillis, p. 45).  

Of note is that only five studies examined received a ranking of five or six in their analysis.  Unfortunately, studies with serious methodological errors (e.g., lack of control group) were included in this analysis and there was no differentiation made between those studies  in the summary scores, seriously limiting any conclusions that can be drawn.  Moreover, post-test only designs were considered to be among the most acceptable of those available, limiting further any conclusions based on this analysis. 

Cason and Gillis (1994) also examined the relationship between design ranking and effect size, reporting that 70.6% of the effect sizes were found in studies without randomly assigned control groups.  They reported a significant negative correlation between research design and effect size, indicating that effect size went down as the methodology employed increased in rigor.  Seemingly in contrast to this, however, Cason and Gillis (1994) report that there were significantly higher effect sizes in those studies that were published as compared to those that were not (e.g., dissertations).  Importantly however, the majority of studies included in the meta-analysis were unpublished.

Overall, they found a summary effect size of .314, which potentially suggests a moderate improvement overall.   However, more important information is found in the variation of the effect sizes, which ranged from -1.48 to 4.26, with a standard deviation of .62.  One explanation for these discrepant findings is the difference in types of outcomes measures, ranging from scores on a math achievement test (4.26 effect size) to movement toward and external locus of control (-1.48 effect size).  One must wonder at the theoretical rational for including such diverse outcome measures in the same overall summary score.  While each may reflect some sort of change, there may be no relationship between such variables.  Therefore, simply comparing change, change seemingly occurring in any domain at all, is meaningless.  This diversity in outcome measures also reflects the clear lack of existing standards for evaluating such programs.

Program variables studied included program length and participant characteristics (e.g., delinquency status, mean age, presence of physical or emotional disabilities, referral source).  This list of variables provides further insight into the amount of methodological difficulties which plague the literature. Given that participants from such diverse backgrounds as school settings and judicial involvement (i.e., delinquents are included within the same sample as other participant groups) are included in the same sample, it is assumed that the impact of such participant characteristics has not yet been examined in any controlled fashion.

The closer examination of these variables leads to even greater concern with regards to the findings.  Program length was considered, and longer programs were found to have greater effect sizes.  However, closer scrutiny of such programs leaves no doubt as to the lack of validity in this finding.  Longer programs typically involve an experience where participants live with their leaders or therapists and the other group members around the clock for some period of time.  These types of programs were included in the same analysis with those that were one day in length.  There is no way to rule out any alternative explanations for reported change based on setting, client characteristics, therapist/leader variables, relationships between participants and the leader, or any other multitude of possibilities.  Without greater control for such variables, there can be no such comparison between effect sizes.  Therefore, this cannot be considered as a valid finding. 

As noted above, widely differing  adolescent population groups were collapsed together in the study.   Although participant characteristics beyond those listed were not considered, Cason and Gillis (1994) claim no difference in effect size based on identified populations.  However, they did note that there was widely diverse instrumentation employed across populations, and that this may impact the results.  For example, they report that treatment populations were often given a battery of clinically-based evaluation measures while “normal” adolescents often completed non-clinical measures such as self-esteem and locus of control.   Given the entirely different rationale behind this array of measures, there can be no true basis of comparison.  Finally, there is no differentiation made between adventure-based therapy programs and basic outdoor adventure programs, further confounding this comparison of effect sizes.

 Cason and Gillis (1994) note specifically that their study is in no way able to answer questions regarding potential differences in outcome based on client characteristics, referral source, therapist variables, or differences in instrumentation.  They note that these such variables are not actually reported often enough in the literature to allow for coding at the meta-analytic level, and state that this is necessary for future research.  They also remark that differences in programming and activities utilized needs to be more closely examined in order to determine what types of program characteristics might impact change, noting that without such descriptions replication and scientific evaluation are impossible (Cason & Gillis, 1994).

Cason and Gillis (1994) further comment that “in order to determine a more meaningful estimate of the effectiveness of adventure programming, empirically based research must develop in a more logical and consistent direction.” (p. 43).  They also state that programs which report no more than program length, and average scores of participants on a particular measure are nor longer useful, a statement that seems clearly obvious to anyone informed by the EST literature  Unfortunately, it is not clear whether such studies were utilized in their meta-analysis, although based on the design considerations it seems likely that in fact some were. 

Clearly, the findings of this meta-analysis must be viewed as invalid and no conclusions can be drawn based on the results. However, as the first attempt to consolidate such findings, it can be used to stress important considerations in conducting such future meta-analytic studies. 

 

Han

Han (1997), in an unpublished masters thesis, also conducted a meta-analysis, focusing specifically on the findings in overall adventure programming with regard to locus of control.  While locus of control may be of limited clinical utility, given the lack of such meta-analytic studies it is important to explore Han’s findings. She examined 24 studies which utilized locus of control as an outcome measure which included 1632 participants.  Mean ages were not reported, and there is very limited information regarding participant characteristics.

In this analysis Han (1997) included only those studies utilizing a pre and post-test assessment of locus of control and reporting what was deemed by Han to be “an appropriate level” of statistical information.  Unfortunately, there is no operational definition given for “appropriate”. In addition, there was no examination or discussion of study design in Han’s analysis and thus there is no information available on which to evaluate the strength of the findings.  Therefore, the results are relatively uninterpretable.  Nevertheless, I will continue with this discussion of Han’s findings on order to continue exploring the relevant literature. 

Han found an overall mean effect size of .36 for locus of control, reporting this as an shift towards intenality across conditions. Such a shift towards an internal locus of control has been shown to be associated with increased self-confidence, decreased anxiety, and higher levels of adjustment and self-esteem (Deery, 1983; Shasby, Heuchert & Gansneder, 1984; Langsner & Anderson, 1987).   Standard deviations were not reported.  Given that we have no information as to the methodological quality of those studies included in Han’s analysis, unfortunately there is no basis by which to evaluate the validity of either of these claims. 

Attempting to build on the findings of Cason and Gillis (1994), Han coded her studies based on program and population characteristics.  The populations were identified by Han (1997) as:  a) clinical, participants who carried some sort of DSM-related diagnosis; b) adjudicated, court referred; c) non-clinical, including school groups, outward bound participants, and volunteers;  and d) non-clinical referred, which included “special populations who were referred but did not carry a diagnosis.” (p. 21).  There were no differences regarding changes in locus of control between populations.  Of note, however, is that only 3 of the studies reviewed utilized clinical populations as compared to 13 non-clinical.  Given the inequality of the sample populations, we can make no generalizations based on this data with regards to effects of programs on specific populations in the area of locus of control, particularly clinical populations. 

Program characteristics reported included the goals of the program, the type of program, and the daily duration of the program.  Program goals included four categories: 1) recreation, 2) education/developmental/prevention, 3) adjunctive therapy , and 4) primary therapy (PRIM).  Programs reporting a primary goal of therapy had a significantly higher mean effect size for locus of control (.64) then did those reporting a goals of education, development or prevention (.35), and adjunctive therapy (.30).

Types of program examined included 1) wilderness/expedition format, 2) camping, or base camp based model, and 3) activity-based model.  (The reader is referred to the earlier discussion of such program types for more information.)  Programs were then categorized on “daily duration” (time spent in the program per day) and included a pure residential setting where participants were together for the entire duration of the program, a semi-residential designation where the program consisted of daily meetings with the participants returning to their respective homes combined with some overnights.  In addition, this category included those participants involved in inpatient hospitals who remained in this setting throughout but for whom the AT intervention was utilized as an adjunct modality.  This appears to be a serious confound, and it is unclear why this was not a separate designation.  The third category included those participants involved in outpatient treatment. 

Outpatient populations showed a significantly lower shift towards internality than did those in the semi-residential or the residential programs. As this is of limited clinical utility, what could have potentially provided more relevant information would have been the analysis of the interaction between program goal and participant group.  Unfortunately, while the data were available to make such comparisons, this step was overlooked by Han (1997).  While any conclusions would have been limited by the aforementioned methodological constraints, such an analysis may have provided preliminary clues for future examination of differential effects across populations, at least as related to locus of control.    

This level of detail is included in this discussion to show Han’s (1997) attempts at a somewhat more rigorous delineation of client and program characteristics.  While is still lacking in such specifics as other clients characteristics, therapist/leader variables, and a clear operationalization of types of programs, when compared to Cason and Gillis (1994) this suggests movement in that direction.  Unfortunately, however, Han’s (1997) study suffers from many of the same methodological errors as does Cason and Gillis (1994).  Aside from the lack of information regarding quality of studies, there is no mention of the utilization of randomization or appropriate control groups, participant or therapist/leader characteristics, or the use of appropriate statistical methods (beyond Han’s (1997) personal designation).  In addition, identified populations were not mutually exclusive, nor were designations of program duration clearly specified.  Furthermore, only 3 of the studies reviewed involved clinical populations, as compared to 13 non-clinical.  Related to this, locus of contort lacks clinical utility for such populations.  

Thus, similar to Cason and Gillis (1994), Han’s (1997) study should not be cited as support for AT efficacy.

 

Hattie, March, Neill, and Richards

Hattie, Marsh, Nell, and Richards (1997) conducted the third meta-analysis to date, with a mean sample age of 22.28, and an age range of 11 to 42 years. They analyzed effect sizes in 96 studies of exclusively Outward Bound programs.  The mean length of program is reported to be 24 days with a standard deviation of 16, indicating wide variability.  Participants were coded as normal, delinquent, or business managers, reflecting the target populations for Outward Bound programs.  No further information was given about the participants. 

As an aside, it is important to note that while Outward Bound programs may achieve some therapeutic goals, the primary focus is not on therapeutic level processing.  In addition, a backcountry setting was a necessary element of those Outward Bound experiences included in their analysis.  Therefore, the results may not be generalizable to programs that are primarily therapeutic in nature and which may vary in length and setting.  However, given the similarities in history and modality between Outward Bound and AT programs, this study may provide relevant background information to the study of AT.

Their meta-analysis also contained a portion of studies that included preliminary testing and follow-up, indicating that 18% of the studies involved responses collected one month prior to beginning the program and 18% contained studies which assessed follow-up effects.  Given the impact of excitement and anticipation immediately preceding a program and the potential for inflated scores immediately following a program, this is an important difference between this meta-analysis and those prior.  Interestingly, however, there were no systematic effects found for prior testing.

Hattie et al. (1997) found a summary effect size of .34, very close to that found by Cason and Gillis (1994).   In addition, they reported an increase in effect size of .17 for assessments conducted up to 18 months after the program ended (mean= 5.5 months), translating to an overall improvement effect size of .51.  They believe that this finding suggests that participants continue to experience growth and change upon returning to their homes.  This can be contrasted to most forms of intervention which show steady losses in treatment gains with the passage of time (Neill & Richards, 1998).

As discussed in the reviews prior, however, one cannot be sure of the quality of such follow-up.  There are no data available as to attrition rates in follow-up, nor are there any data available as to the setting that participants were released into. Therefore, it is impossible to separate the effects of self-selection in the follow-up (i.e., those with unfavorable outcomes may have dropped out of the study), as well as the effects of environmental considerations upon release.  There are also no data available on what types of outcomes were examined for follow-up and who gathered this data.   Important future considerations when examining such data include knowing how improvement was defined and in what domains was it evaluated, as well as knowing whether there was any experimenter bias associated with the data. 

Hattie, et al (1997) did conduct an analysis of study quality and excluded from their meta-analysis those studies which they judged to be of low quality.  They found no differences in mean effect sizes for those studies coded as high vs. medium quality, therefore they did not separate the conclusions.  Unfortunately, the definitions of what constitutes low, medium and high quality studies are overly vague.  Low quality studies were defined as there being “no information available on the quality of the test” (p. 58).  Studies rated as medium quality included those where “some attempt was made to reference psychometric qualities of the test” (p. 58), and studies rated as high quality were based on the study being “published and/or norms available in publications” (p. 58). 

While this is a positive attempt at deleting those studies of poor quality from any sort of scientific consideration, there needs to be further information available as to the quality of the data included in the analysis before a truly informed decision can be rendered regarding the conclusions of the meta-analysis.  The limited information provided by Hattie et al. (1997) is imprecise and relatively uninterpretable.   Nevertheless, this is clearly a positive step when taken in the context of the scientifically impoverished AT literature.

In addition, related to problems related to ratings of study quality,  Hattie et al. (1997)  noted that small sample sizes for most of the studies reviewed led to low power, estimating that the average power of the studies they included in their analysis was .65 for medium effect sizes, pointing out that therefore these studies contain statistical power below the accepted level of .80.  They discuss this finding in the context of the literature in this area, noting that “it is perhaps no surprise (given the low sample sizes) that evaluators sense major change but are frustrated at not detecting statistical significance” (Hattie et al., 1997, p. 49).    They report that by using meta-analytic techniques, they were able to use an “alternative methodology” that “avoids the pitfalls of using small samples, capitalizes on the diversity of outcomes and programs, and is not as concerned with statistical significance” (p. 49).   However, this statement is questionable when considered in the context of the above noted information provided regarding the quality of those studies reviewed.  

Hattie et al (1997) found no immediate differences between effect sizes for participants based on background ( i.e., “normal”, delinquent, or business managers)  They report, however, that the mean effect size at follow-up is greater for delinquents than the other two groups (mean =.34), and it is possible that this increased mean may be due to the wide range in reported follow-up effect sizes for this group (range =-.05 to .74).  Standard deviations were not available.  Age and gender were examined for the first time in these meta-analyses as potential moderating variables.  Hattie et al. (1997) noted difficulties in examining age as a moderator variable of effect size, indicating that there was too little information available about the ages of participants in the studies included in their analysis.  As an attempt at examining these effects, they split the studies into two groups, one utilizing school age participants and one using adult participants (including university students).  They found a greater effect size for adults with immediate post testing, although the follow-up mean was similar for both groups.  The authors note, however, that this may be an effect related more to self-selection due to motivation rather than an actual increased change mechanism for adults, and discuss the need for reported participant motivations in future research.  It may be that school-age participants are referred unwillingly by parents or school staff, whereas adults are much more likely to be volunteers. Gender was also examined and while Hattie et al. (1997) note there are confounds in that most studies utilize mixed-gender groups, they claim it appears as though there are no differences in effect sizes for male female participants.

 Hattie et al. (1997) also broke the program type into specific categories, differentiating between wilderness/expedition programs and adventure programs utilizing less extreme physical challenges.  They report that wilderness programs appear to have the highest effect, but claim that the success of these programs with delinquents skews these results.  In addition, they examined the length of the program and concluded that longer programs (those greater than 20 days in duration) have higher effect sizes, however they note that there is an interaction between this finding , age of participants and country of origin (Australia vs. the United States).  They state that for student-age participants the effects were similar regardless of length of program or country of origin and that for adults the results were more marked for longer programs in Australia as compared to the United States, perhaps indicating an underlying and unexplored difference in those participants from different countries in their response to the program.  This examination of the interactive effects is much applauded, given that such a potentially important avenue was overlooked in the previous analyses. 

Outcome was coded into six dimensions which encompassed a listing of different subcategories subsumed under these major dimensions, and separate effect sizes were computed for each dimension and specific subcategory (note-in the interest of brevity, the reader is referred to the original article for individual subcategory effect sizes):  leadership (effect size=.38, subcategory range of .46-.05) , self-concept (effect size=.28, subcategory range of .47-.08), academic (effect size=.24, subcategory range of .50-.45) personality (effect size= .37, subcategory range of .49-.10), interpersonal (effect size=.32, subcategory range of .55-.13) and adventuresomeness (effect size =.38, subcategory range of .39-.24).   Of note is that there are no clinically-related outcomes, which may be understandable given that the programs examined were not specifically therapeutic in nature.

Hattie et al. (1997) report that “the effects across these six dimensions are systematically high” (p. 66).  Follow-up effect sizes for each outcome dimension are also considered and they report that these effects are maintained over time for all categories but adventuresomness.  While an outstanding finding, this appears to be a fairly sweeping assertion and it may be important to expand on such claims.  Unfortunately, as noted the necessary information on study quality required to truly evaluate such claims is unavailable. 

Hattie et al. (1997) were also the first of the meta-analytic reviewers to employ statistical techniques beyond effect size comparisons when analyzing their data.  Reportedly using setwise regression, they claimed that 36% of the variance in effect sizes could be explained by the program effects, background effects, outcome effects, and study effects.  Interestingly, they found the least amount of variance could be attributed to study variables, although this may be reflective of their limited definition of what constituted study quality.  Interestingly, this finding is in contrast to Cason & Gillis’s (1994) finding that effect size increased as study quality went down.  However, this could potentially also be a function of the fact that Hattie et al. (1997) excluded those studies they deemed of poor quality from their analysis.  Also based on the regression analysis, on the participant level they claimed that the most variance was explained by participant age, length of program (two categories, longer or shorter), and country of origin. This appears to be one of the first attempts at examining the interaction between program effects and participant effects.

Clearly, this meta-analysis has moved beyond many of the criticisms leveled at the previously addressed studies.  However, the overall validity of any meta-analytic review is based on the quality of the studies included and this study leaves this question unanswered.  The definitions given were not specific enough to allow for any true evaluations of the quality of those studies reviewed.  Therefore, there can be no conclusions with clear validity drawn from the results.  While it can be used to guide further analyses that examine the issue of study quality much more closely, the results of this study remain inconclusive.   Nevertheless, given the increase in methodological sophistication found in this study as compared to those reviewed previously, it is worthwhile to provide a summary of the methodological improvements. 

The continued inclusion of statistical procedures beyond simple comparisons of effect size (i.e., regression analysis), utilized by Hattie et al. (1997) and the examination of interactions between variables could potentially provide us with a much greater understanding of the relationships between variables.  Hattie et al. (1997) also attempted to further define client characteristics, even at the most simplistic level (i.e., participant age) and examined the interactions of this characteristic with other variables.  While the lack of information given regarding client characteristics in the studies they reviewed precluded any analysis beyond the breaking of participants into basic groupings, this was an important step was overlooked in the previous two analyses.  In addition, they also examined the effects of gender.  It is unfortunate that the state of the literature in AT is such that additional characteristics are rarely available.

The detailed analysis of the outcome data was also more thorough in this study.  It appeared that the groupings of the outcome measures were well thought out and information about the specific sub-categories was given when relevant to achieving greater understanding. Such information was also unavailable in the previously reviewed studies.  In addition, the detailed analysis of the follow-up data related to specific outcome gives us insight into the importance of such data for future evaluations.  Further information could have been provided about the format of the programs examined.  While the programs were broken into two groups, expedition and adventure, there is limited information to be gained from this distinction and a further break-down of program characteristics would have been useful.

Given that the meta-analysis conducted by Cason and Gills (1994) as well as Han (1997) both suffer from similar methodological flaws, it unfortunately appears that we can reach no solid conclusions about adventure programming based on any of these reviews.  Chambless and Hollon (1998) comment on the usefulness of meta-analyses, noting that “We think it is unwise to rely on meta-analyses unless something is known about the quality of the studies that have been included and there is confidence in the data.” (p. 13).  Unfortunately, for these three meta-analyses such is not the case.   Sadly, this seems to reflect the current state of the AT literature, and while such efforts to consolidate the AT literature are laudable, they may perhaps be premature.  Such reviews may be better conducted when the field overall has reached a state where there is enough high quality literature available to conduct truly meaningful meta-analyses.  Further insight into this problematic issue may be gained in the examination of the studies which follow.

 

Use of Adventure-Based Therapy  with Adults

 

            There have been four studies that have recognizably added significant contributions to the literature relating to AT with adult populations.  In this section,  studies by Kelley (1993), Banaka and Young (1985), Kelley, Coursey, and Selby (1997), and Herbert (1998) will be reviewed in detail.  The section will end with a brief summation of other studies with adult populations.

 

Kelley

In an review of the AT literature with mentally ill adults, Kelley (1993) similarly notes that the methodology employed in the studies he reviews is inadequate due to lack of rigorous controls and psychometrically adequate comparisons.  Kelley reviewed 17 studies in this area which involved both adventure-based therapy alone as a treatment modality and adventure-based therapy as an adjunct treatment.  Of the studies he reviewed, he notes that only one of those came close to reaching methodological adequacy.  In fact, the majority of the studies simply base their conclusions on anecdotal evidence.

Similar to those included in the meta-analyses, problems with the studies Kelley (1993) reviewed included lack of a control group or a lack of equivalent testing of the control group, lack of post-test data, use of unstructured interviews or instruments with no reported reliability or validity data, a lacking of statistical analyses or inadequate documentation of reported analyses, and the use of anecdotal reports as evidence of improvement.  In addition, Kelley discusses such confounds with this population as novelty effects and effects of antipsychotic medication on physical performance.  Therefore Kelley notes that there can be no interpretation of the data in this area regarding the efficacy of such adventure-based interventions for mentally ill adults.  Given these severe methodological errors, the flawed studies will not be reviewed here in detail and reported outcomes will be listed only to provide illustration of the types of outcomes examined as the data is not considered to be valid.  

These cited studies included hospitalized inpatients, psychiatric day-treatment patients, and PTSD war veterans.  Reported outcomes included a reduction in obsessive thought patterns, deceased fears of overwhelming dependency, increased self-esteem, increases self-confidence, and greater affective awareness (Slosky, 1973, cited in Kelley, 1993), increased rates of discharge (Jerstad & Seltzer, 1973), increases in appropriate social interaction and congruence between real and ideal self conceptions (Jones, 1972, cited in Kelley, 1992; Tuttle, Terry, & Shineedling, 1975), increased self-efficacy (Shank, 1975), increases in communication and alertness, greater initiation of responsibility and improved grooming (Keith, 1978), increases in personal pride and self-esteem , and overall therapeutic benefits (Myers, 1982), and decreases in PTSD symptomatology (Wilson, Walker, & Webster, 1989).  Other studies published after Kelley’s review have examined the use of adventure experiences for persons with physical and mental disabilities (Herbert, 1998; McAvoy, Schatz, Stutz, Schlein, & Lais, 1989).

Echoing the earlier critical discussion, Kelley (1993) suggests that future research is necessary in this area which employs such standard research designs as control group comparisons, randomization, and the use of appropriate psychological measures with demonstrated validity for mentally ill populations.  In addition, he also discusses how few studies have utilized long-term follow-up data and that data of this sort is necessary to address the long-term utility of such interventions.

 

Banaka and Young

As noted, there is one study discussed by Kelley (1993) which employed more appropriate methodologies.  Therefore, this study will be reviewed in detail.  Banaka and Young (1985) reported the effects of a two-week wilderness camp on skills related to community coping for chronically mentally ill participants.  Chronically mentally ill adult men and women, most diagnosed as schizophrenic, from two state hospitals were nominated by hospital staff based on chronicity and staff perceived adaptability to the program.  Mean age of participants was 30.  Participants were screened by interview to further determine eligibility and were randomly assigned to the control or the experimental group.  However, 20 of this group chose to not participate and were replaced by controls, leaving a total number of 48 participants and 31 controls.  Therefore, while there were solid attempts at random assignment there was still no rigorous way to control for selection bias in the groupings.

The staff for the camp included 12 hospital volunteers and 12 professional guides, six of whom had no association with the hospital.  There is no further information available on the staff.  Two staff involved in the program and the participants themselves filled out rating forms covering five domains: personal care, formal social system, informal social contacts, social acceptability, and task orientation.  Measures were taken at pre-test, one time during the two-week intervention, at post-test, and three weeks post-completion.  The control group participated in the standard treatment regimen.  There were no differences found between the scores of the control group for time 1 to time 2, therefore there was no additional data collected for controls and these early scores were used as comparisons.  Results showed that the experimental group was significantly improved on seven of the ten scales at the camps close and that those changes were maintained for three weeks post completion on four of the seven scales at follow-up.

A six month follow-up showed a significant difference in discharge rates for the experimental groups (92.7% as compared to 55%), although variability information was not provided.  The experimental group spent significantly more time in the  community following discharge, and rehospitalization costs of controls were twice that of the experimental group.  This suggests the possibility of cost effectiveness for such a treatment.  Regression models were employed, and the experimental group change scores on 4 of the 10 scales from  pre-testing to three week follow-up were predictive of community-based success (Banaka & Young, 1985).

This study is one of the better conducted to date, employing attempts at randomization, an adequate control group, and appropriate follow-up, as well as more sophisticated statistical techniques.  In addition, this is the first study reviewed which made any attempt at assessing the impact of individual differences in change scores on successful outcome.  However, it still suffers from methodological inadequacies. 

To elaborate, the measures used by Banaka and Young (1985) were devised for the purposes of the study and therefore there is no psychometric data available for the measures.  The staff conducting the ratings were also participant-observers, and therefore the ratings themselves were subject to experimenter bias.  The lack of testing of controls at post-test and follow-up leaves open the possibility of maturation effects, Although the one month that elapsed is a fairly short amount of time, this amount of time elapsing may have greater relevance when considering the effects of such time for psychiatric inpatients. The statistical procedures utilized were also somewhat inadequate.  In addition, there is minimal information available on the participants, and such information as length of time spent prior to the program in the hospital and further diagnostic information would have been helpful in evaluating generalizability.  As aforementioned, there is also the problem of selection bias. Finally, there is no information available on the staff/therapists who conducted the two-week wilderness camp, specifically regarding their expertise or familiarity with therapeutic principles, nor is there any specific information available on the program itself.  Information such as this is necessary in order for such findings to be compared to the effects of other similar programs in the future.

 

 

Kelley, Coursey, and Selby

Kelley, Coursey, and Selby (1997) conducted one of the most well thought out and clinically relevant studies to date, utilizing a chronically mentally ill population and stating expressly therapeutic goals.  Participants involved in outpatient psychosocial rehabilitation programs were recruited to participate in an adventure program which consisted of nine weekly day-long outings focusing on sequentially more challenging adventure activities (e.g., hiking, rock climbing, caving, and canoeing) in groups of 8-12.  In addition, this program also integrated a self-instructional training (Meichenbaum & Cameron, 1973) component into the activities, thus integrating specific cognitive-behavioral techniques.

Staff included clinical psychology master and doctoral level students with extensive outdoor experience, as well as other experienced student leaders.  Some groups included agency staff as well, and all staff received further training in leadership throughout the program. 

Participants were separated into two diagnostic groups, schizophrenic (N=36) or affective or schizoaffective disorders (N=33).  The experimental group consisted of 50 mixed gender participants and the control group consisted of 19 participants.  Mean age of participants was 31 and participants had been in treatment for an average of ten years.    All participants attended the same rehabilitation center and volunteered for the program.  The control group was provided by those participants who were unable to participate due to scheduling conflicts, as well as those who had to drop-out of the program due to later arising conflicts (e.g., procured employment, scheduling difficulties).  Participants were screened for psychological and physical suitability for the program prior to admission.

 Pre-test self-report measures were completed while waiting for admission to the program and also just prior to beginning the program.  Controls completed such measures at an equivalent interval.  There were no differences found between the experimental group and the control group on such measures, nor were there any reported changes for either group during the wait-list period (approximately 9-10 weeks).  Additionally, the experimental group completed the measures upon finishing the program, while the controls completed the measures at an equivalent nine week interval.  Unfortunately, there were no follow-up data available.

Clinically relevant dependent measures were used to assess the following areas:  self-esteem and self-efficacy, using several self-efficacy scales and one self-esteem scale (Rosenberg, 1965); anxiety and depression, using the State-Trait Anxiety Inventory, Trait Version (STAI; Speilberger, Gorusch, Lushene, Vagg, & Jacobs, 1977); the Beck Depression Inventory (BDI; Beck & Sterr, 1987), and the Anxiety and Depression subscales of the Brief Symptom Inventory (BSI; Derogatis & Melisantros, 1982); trust vs., paranoid tendencies; and locus of control.  Additional psychiatric symptoms were also measured using the remaining subscales of the BSI (Kelley, et al, 1997).

The data were analyzed using multivariate analysis of covariance (MANCOVA) techniques, with pre-test scores as covariates and post-test scores as the dependent variables. Results showed significant increases in self-esteem and self-efficacy for the experimental groups and decreases in such areas for controls.  Interestingly, significant decreases were found for both groups on the BSI anxiety and depression subscales. Kelley et al (1997) report that the differences were larger for the experimental group, although it is unclear if this is a statistically significant difference.  No differences were found on the BDI.  There was no main effect for the intervention in the trust vs. paranoia domain, but a significant interaction emerged for group by diagnosis in this area.  Examination of this interaction revealed that on the Trust and Cooperation scale, experimental participants with affective or schizoaffective disorders showed significant increases in these areas.  For schizophrenic participants the results were moderately reversed.  For the BSI subscales of Interpersonal Sensitivity and Hostility, decreased symptoms were shown for all experimental participants, while schizophrenic controls showed increases and controls showed decreases.  No differences were found in locus of control or other psychiatric symptoms.  This finding with regards to locus of control seems to contradict other studies in this review.  Overall, results suggest that there may be an immediate effect for adventure participants in the areas of self-efficacy, self-esteem, anxiety, depression and trust.  In addition, there is the suggestion that participants in different diagnostic groups may respond differently to the intervention. 

This study is noteworthy as it is the only study to date that utilizes a battery of measures addressing changes in specific pathological symptoms, and the only study that examines differences in AT outcome across such groups.  In addition, it is also the only study  that specifically delineates a clearly recognizable use of a specific therapeutic orientation (self-instructional training), along with other more common AT therapeutic principles such as group level processing, challenge, sequencing, etc..  The use of clinically trained staff is also worthy of mention, as is the use of statistical procedures of appropriate sophistication.  Future studies employing similar methodologies could employ regression techniques as well in order to analyze any utility of pre-test measures or change scores as predictors of change.

While noteworthy for all of these reasons, this study still suffers from problems with standardization that raise questions of validity.  There were particular problems with standardization of groups.  The control and experimental groups contained differing numbers of participants, as well as differences in their diagnostic composition, thus leading to a lack of equivalence.  In addition, the AT experience across experimental groups seemed to differ substantially.  Participants were only required to participate in three of the adventure groups, and therefore attendance fluctuated.  This may have potentially impacted the nature of the group experience and also may have contributed to individual differences in the experience.  Such differences in participation may have led to differences in level of change reported, thereby impacting the overall group mean.  The sequencing and choice of activities was also different for groups based on the time of year and instructor expertise.  Furthermore, the composition of instructors/therapists for each groups varied, with different training levels and numbers of staff across groups.  This may have led to differences in the dependent variables based on therapist effects.

The use of drop-outs as controls is also questionable, although wait-list measures indicated no between group differences and no differences between those that were unable to participate for scheduling reasons vs. those who dropped out for comparable reasons. Differences in motivation between groups, however, may have indirectly impacted the results.   

Nevertheless, this study is the most clinically relevant of all available studies to date.  While suffering from methodological inadequacies related primarily to lack of standardization, the suggestion of impact for an AT intervention with a population such as  this is worthy of further investigation which attempts to control for those factors mentioned. Future research should also attempt to employ standardization of training levels, experience, etc. of staff.  It is worth noting, however, that difficulties in standardization of client experience plague all psychotherapy researchers. In addition, further delineation of the use of such therapeutic techniques as self-instructional training should be provided in order to begin considering the potential impact of such techniques on the overall intervention.  Finally, follow-up must be implemented to determine if such therapeutic gains are maintained over time.  This is of particular importance when evaluating an AT intervention due to potential effects based on novelty or exercise.   These and other methodological issues will be further addressed it the later chapter focusing on methodological considerations in AT. 

 

Herbert

Herbert (1998) conducted another study in this area which employs appropriate scientific rigor, examining the effects of an adventure-based therapy program on sustaining employment for disabled adults.  Thirty-eight participants were recruited from community based rehabilitation programs and randomly assigned to the no treatment control group or the experimental group.  The eight-day AT program involved backpacking, canoeing, rock climbing, ropes course activities, camping, and team initiatives. In an attempt to provide an element of control to the treatment, the activities were identically sequenced and the facilitators remained the same for each group.  Initially Herbert planned three groups, one group receiving the eight- day intervention alone, one receiving the eight-day intervention plus a three-day follow-up intervention at three months post-completion, and a control group.  Unfortunately, the follow-up was canceled due to inclement weather (flooding) and the scores of the two experimental groups were collapsed.

Pre and post-test measures of locus of control scale and self-esteem were administered to the experimental group and the control group at a comparable eight- day interval. Dependent measures and qualitative interviews were completed at three months follow-up and the dependent measures were again administered at one- year follow-up.  Employment records were also examined for one year following the intervention.

Adult participants included both males and females carrying the diagnosis of schizophrenia, moderate metal retardation, personality disorder, orthopedic disabilities or multiple disabilities. Mean age of the experimental groups was 25.87 and 23.83 for controls.  The adventure facilitators included experienced adventure facilitators unknown to the participants, as well as two volunteers from the supported employment program with whom the participants were familiar.

Results showed that participants had increases in self-esteem and locus of control immediately following the intervention.  However, this change dissipated in the year following the treatment.  No impact was found on sustained employment.  Participants responses to the qualitative interviews revealed that participants felt the treatment helped them to feel better about themselves, helped them to recognize they had greater abilities than they thought, and helped them to acquire better skills in handling interpersonal situations.

While this study did follow such crucial design considerations as appropriate control group comparisons and randomization, as well as attempts at standardization through the use of similarly sequenced activities for each group and the same facilitators, it still leaves open the question of whether the treatment itself led to the increases in self-esteem and locus of control.  While the sequencing of such activities was in fact documented and attempts were made to follow a planned curriculum, there is still the question of whether there is an appropriate level of standardization to consider this a well-controlled experiment.  It is possible that any results were simply due to novelty effects.  It is also possible that the relationships made with the facilitators over the eight-day period may have contributed to such an increase.  Indeed, there may have been a significant effect associated with the fact that two of the staff members from the sustained employment program were also facilitators, leaving the study open to bias due to therapist effects.  Unfortunately, however, given the populations included, it is may be necessary to always include such staff on such an excursion in order to help maintain the psychological stability of the patients and to help them attend to any special needs.  This may be a difficulty inherent in conducting such a study, and leads to the long-term necessity of possibly creating and examining more integrated programs (Herbert, 1998)  

In addition, there is also self-selection bias inherent in such a voluntary treatment. There may be individual differences impacting those who chose to participate in ways that may be different from those who choose to abstain.   Therefore, the results may not be generalizable to those who choose to not participate in such activities. Perhaps further qualitative analysis, while being unable to lead to solid empirical conclusions, could help to further elucidate the mechanisms leading to such increases in outcome measures.  This type of analysis may give us insight into whether it is actually the treatment that effects change, or whether there are other variables which may be systematically effecting the results.

Herbert’s (1998) results also point to the need for follow-up in such programs to attempt to facilitate the maintenance of treatment gains over time.  In addition, there needs to be information given as to concurrent treatment of participants in order to potentially address the impact of such treatment and how this can interact with the effects of a specific adventure-based intervention.  Perhaps treatment could be integrated into the follow-up program such that those care-givers involved with the participants upon completion of the program could work to build-on the learning and growth that occurred in the intervention in order to maintain such gains in ways that may have lasting impact on the participants.

Herbert’s (1998) study, while showing some methodological difficulties, also suggests to us that such a treatment may impact participants’ views of themselves in a positive way.  While it is impossible to make any interpretations as to the mechanisms of such change, it seems that such a program may have some immediate effect.  Further research examining the process of change and the impact of individuals differences on such change is necessary in order to draw any further conclusions.

 

Other Studies

AT is also commonly used as treatment for substance abusers, both adults and adolescents. Bennett, Cardone, and Jarcyzk (1997) conducted a study of 13 individuals involved in an integrative relapse prevention program that included a three day team building intervention.  Controls participated in a similar relapse program which did not include the  three day AT intervention.  Data immediately upon completion of the AT intervention suggested that the experimental groups scored significantly lower on measures of autonomic arousal, frequency of negative thoughts, and alcohol cravings.  At ten month follow-up, there were no statistically significant differences in abstinence rates, although they report that the experimental groups rate of abstinence was higher (69% for the experimental group as compared to 42% of the control group). 

Unfortunately, however, there is no way to separate the effects of the AT part of the intervention from the other components.  While perhaps one can infer that the AT program may have reduced stress levels immediately upon completion of the three day program, there can be no conclusions drawn due to the lack of control.  In addition, importantly there were no long term significant difference between groups. 

Interestingly, while there is no empirical data is available to support any claims of efficacy, it is illustrative of the widespread use and diversity of such programs to look at the results of a survey conduced by Gass and McPhee (1990).  In a survey of all recognized AT programs in the United States, of those that participated in the survey 61 programs were identified as working with substance abuse populations.  Of those programs, 40% worked with adolescents. Single day experiences were used by 64% of the programs (no information was provided as to adjunct treatment) and 10% of the programs were over 15 days in length.  70% of programs, however, were affiliated with hospitals or other treatments centers.  The reported average for number of clients served per program was 50 individuals per year, and no information was available on variability of responses.  If we take this as a valid number, that translates to these AT programs serving approximately 3000 clients per year.  It is striking to consider the widespread use of such programs considering the lack of empirical data supporting such an intervention.

Other reports of AT efficacy with adults, albeit not empirical, can be found as well.  Anecdotal reports exist advocating the use of adventure-based therapy with persons suffering from bulimia nervosa (MacGuire & Priest, 1994) and Borderline Personality Disorder (Nurenberg, 1986), antisocial offenders (Reid & Matthews, 1980), as well as severe body image disturbance (Arnold, 1994).   Similar reports have been written for the use of AT with victims of rape, sexual assault, and incest (Asher, Huffaker, & McNally, 1994; Levine, 1994).  These reports include specific considerations for using AT with these populations.  However, no data is presented to support their claims of efficacy. 

Witman and Preskanis (1996) also reported positive benefits of adventure activities in a qualitative case study of a 37 year-old man with Dissociative Identity Disorder.  The man was involved in concurrent inpatient psychiatric treatment and was monitored closely for signs of psychological distress throughout. Prior to the involvement in the adventure challenge group, this man had been described as being particularly withdrawn from other groups and social contacts, as well as experiencing frequent suicidal ideation and identity issues.  Upon completion of the eight- week intervention, it was reported that this man increased in trust, leadership ability, and problem-solving, and decreased in social withdrawal.  The authors report that the man attributed these changes primarily to the adventure challenge group.

While the utilization of the case study method allows for no generalization and no interpretation of the data presented, this opens the possibility that such an intervention may be useful as an adjunct treatment for other mentally ill patients.  Importantly, however, the authors of this case study caution that such an intervention is not to be utilized with all psychiatric patients and that patents must be screened for suitability prior to beginning the activities and closely monitored through the time in which they are involved in order to prevent psychological harm (Whitman & Preskenis, 1996).  Given the severity of DID, such results must be viewed with extreme caution and substantial further research is necessary in order to draw any conclusions about the usefulness of adventure-based interventions for this or any mentally ill population.

 

Of the literature reviewed here, only the studies by Kelley, Coursey, and Selby (1997); Banaka and Young (1985); and Herbert (1998) came close to approximating the methodological rigor necessary in order to draw solid conclusions based on the data.  While still lacking in the controls necessary to make clear scientific inference, there appears to be enough evidence to suggest the possibility that such interventions may yield immediate positive results in the area of self-esteem, depression and anxiety, and trust, and also that gains in community-based coping skills may be maintained over time.  Results with locus of control were mixed.   However, further well-controlled research is necessary in order to verify and expand such claims and at this point it is clear that we do not have enough rigorous scientific data available to either accept or reject the null hypothesis. 

 

Use of Adventure-Based Therapy with Adolescents

 

            Along with adults, AT has been commonly used with adolescents and there are several studies which claim to have found positive results. The following section will focus first on general findings based on a review by Bandoroff (1989).  It will then focus on findings for adolescents with regards to recidivism, first in those studies that compare recidivism rates of adolescent juveniles who participate in an AT program with those of institutionalized juvenile delinquents and next for those that compare recidivism rates for delinquent AT participants with those on probation.  This section will then review those studies with adolescents court-referred to an AT program.  Finally, this section will review of those studies with adolescents focusing on self-concept change through AT participation, and end with a review of other studies that do not fit specifically in these categories.

 

General Findings

Bandoroff (1989) in an extensive but unpublished review of the literature with delinquent and pre-delinquent adolescents reported lower recidivism rates, more realistic self-perceptions, and more positive social attitudes and adjustment, along with an increase in an individual’s sense of belonging.  From this review, Bandoroff concludes, perhaps prematurely, that “It seems clear from this review of the literature that the field of adventure programming has succeeded in justifying itself as a viable therapeutic intervention for delinquent youth.” (p. 55).   

            Bandoroff (1989) breaks his review down specifically into design categories.  In the first category of one group pre- and post-test designs and non-equivalent control group designs, Bandoroff reports significant improvement in self-esteem, social adjustment, and social attitudes, as well as other areas more specific to each outcome measure utilized.  However once again the conclusions that can be drawn are limited by the lack of appropriate comparison groups and therefore will not be expanded upon.  Of note, however, is that Bandoroff reports that some of these studies did employ follow-up procedures and this follow-up data suggested that perhaps some of these gains may be maintained over time.  Such follow-up designs may be worthwhile to pursue in the future in order to determine whether or not any reported gains can in fact be maintained.

The second category is non-equivalent control group designs.  Interestingly, these studies found similar conclusions regarding increases in self-concept and related constructs, although Bandoroff (1989) notes that “these results are not as conclusive in their findings regarding self-perceptions as those studies previously discussed” (p.31).  It is interesting to note that there is a suggestion here that as methodological rigor is increased, strength of findings are decreased, paralleling  findings of Cason and Gillis (1994).  Bandoroff discusses further methodological difficulties in these studies such as lack of equivalency in sample sizes between the experimental and the control group and wait-list attrition when using wait-list controls. 

Importantly, Bandoroff (1989) also cites a study in this category which found no differences in self-esteem between a group participating in an AT program and a control group that remained institutionalized, with both groups showing improvements.  Not surprisingly, however, a six month follow-up interview reported those participating in the AT experience had more positive views of their experience than did those who remained institutionalized (Birkenmayer & Polonski, 1976; cited in Bandoroff, 1989).

 

 

 

 

 

Recidivism

 

            Adventure-based therapy vs. institutionalization

            The third category of studies reviewed by Bandoroff (1989) used recidivism rates as an objective outcome measure.  These studies will be reviewed in detail.  Kelley and Baer (1971) conducted a two year study of 120 adjudicated male adolescents between the ages of 15-17 matched on IQ, race, religion, offense, area of residence, and number of previous commitments. History of violent assault or sexually related offenses were exclusionary criteria.  While randomly assigned to an experimental group or a control group, participation in the program was dependent on a stated willingness to participate if selected for the experimental group.  No data are available on the numbers who chose non-participation and therefore we can make no inferences as to possible effects of selection bias. 

Control subjects were treated in the standard manner, including institutionalization in juvenile facilities and parole.  Experimental participants were referred to one of three Outward Bound programs involving heterogeneous groups of delinquents and non-delinquents. At one year follow-up, 20% of the experimental group had recidivated as compared to 42% of the controls. Of note is that the national average recidivism rate for juveniles during those years was reported to be 40%, directly in line with that of the controls. 

Importantly, however, one of the Outward Bound schools had substantially higher recidivism rates than the other two schools. The authors note that this program had lower levels of physical challenge and excitement than did the other two, emphasizing endurance and personal challenge more.  However, there are also many additional possibilities to explain such results related to program variables, instructor variables, or the interaction of participant characteristics with the program.  This points to a potentially serious lack of standardization across programs.  Kelley and Baer (1971) note that importantly, however, without this program included in the analysis, the results may have been even more striking as statistically this high number would have altered the mean effects of the other two programs. 

One final noteworthy point is that those juveniles whose offenses occurred in the “stubborn-runaway” category were three times as likely to recidivate in both groups.  When this group is removed from this analysis, differences in recidivism rates between the experimental and the comparison groups become more pronounced.  Kelley and Baer (1971) speculate that these differences may relate more to the nature of home environment that the participants were released into (i.e., one can speculate that there may have been increased problems in the home environment that led to running away), and that  follow-up programs should perhaps be specifically targeted to such individuals.

A five year follow-up by Kelley (1974; cited in Bandoroff, 1989) showed that after five years there were no more significant differences in recidivism, but that it appeared that the experimental group overall cost the state less money in treatment, spent less time in holding facilities, and committed less serious crimes, suggesting the possibility of increased treatment efficiency for the AT approach.   

These studies show that it is likely that adventure programs may have some impact on recidivism, albeit short-term, although again we are unclear as to the mechanisms of that impact.  It is also important to note that the programs did not appear to impact all participants in the area of recidivism.  However, there is no data available on the number of participants for whom follow-up data (recidivism) is available and thus we cannot be sure if any follow-up data simply reflect a subset of these individuals.

Willman and Chun (1973) replicated the results of Kelley and Baer (1971), evaluating a program developed by the State of Massachusetts in response to Kelley and Baer’s (1971) results.  Attempting to control for possible grouping effects related to Kelley and Baer’s (1971) use of heterogeneous groups, Willman and Chun used homogeneous groups of delinquent adolescents and tracked 300 boys for the one year period following completion of the program. 

While finding similar recidivism rates similar to Kelley and Baer (1971) of 20.8% for the experimental group and 42.7 % for the control group, they also found that the experimental group remained uninvolved with the legal system for longer, noting that only 38% of the experimental group re-offended in the first six months as opposed to 72% of the control group.  They also found that older participants and those who had completed a higher grade level in school had higher success rates.

Additional important findings of both Kelley and Baer (1971) and Willman and Chun (1973)  are that variables such as age of first court appearance, presence of both parents in the home, age of first institutionalization, and type of offense were factors which were related to recidivism (Bandoroff, 1989).  Therefore, these factors should be included in future studies as variables of interest.  It was also noted that the adventure intervention appeared to be more effective for persons who committed a crime against person or property (Bandoroff, 1989).  

Further information as to the environment the individuals were released into and treatment upon completion of the AT program is necessary in order to determine whether or not such recidivism data can in fact be attributable to the intervention. In addition, further information is necessary on the variability of such recidivism rates in order to make global claims as to effectiveness.  It is possible that such an intervention may have been very effective for some and ineffective for others.  If this is the case, then such effects may be hidden by looking at group averages.  In such future studies it may be necessary to look further at the effects of the program on individuals and determine whether there are individual variables related to program effects which impact such outcomes (e.g., change scores on specific outcome measures).

 

Adventure-based therapy vs. probation

Bandoroff (1989) reviews two other studies he views as employing true experimental designs.  These studies compared adolescents involved in standard probation programs with those involved in an AT program.  Employing similar designs as Kelley and Baer (1971) and Wilman and Chun (1974), trends towards improvement were noted, but there were no significant differences between groups (Boudette, 1989; Winterdyk, 1980; cited in Bandoroff, 1989).  Each included follow-up data as well.  Therefore, Bandoroff (1989) states that neither of these studies were able to produce conclusive results as to the effectiveness of a wilderness intervention for delinquent youth, and it may be that there are minimal differences in recidivism found between participants in an AT program and a standard probation program.  This premise needs further exploration.  Interestingly, however, Boudette (1989, cited in Bandoroff, 1989) discusses qualitative data that supports improvements in the groups participating in the AT program (i.e., interviews with parents).

Unfortunately, each of these studies remains an unpublished doctoral dissertation, and thus the results have not been subjected to the same extensive peer review processes as are those studies published in well-established journals.  Nonetheless, according to Bandoroff (1989), these studies employed “excellent methodologies utilizing multi-modal and multi-method assessment with good convergent validity” (p. 39).

Castellano and Soderstrom (1992) also attempted to evaluate the impact of an adventure program on juvenile recidivism.  Thirty- six adolescents participated in a standard wilderness program and a comparison group matched on gender, age, ethnicity, date of first court referral, and the offense class was selected from the country probation office.  Analysis of the matching criteria indicated matches on all characteristics except for seriousness of offense, with program participants engaging in more serious offenses than their otherwise matched controls. 

Results of this evaluation showed that there were no differences in overall first re-arrest rates between those that participated in the adventure program and those who did not.  However, the results showed that the seriousness of the crimes perpetrated after the program was significantly less as compared to controls.  This is in contrast to the reported greater severity of crimes for this group prior to program participation.  Any differences found, however, appear to be obscured after two years. 

Multiple measures of recidivism were used in this study including overall recidivism, crime specific recidivism, arrest rates, and a frequency/seriousness index of recidivism.  While analysis of these different categories for recidivism showed trends towards positive effects for program participation, there are no clear findings and the possibility remains that there were no effects on recidivism based on program participation.

One important difference in this study reported by Castellano and Soderstrom (1992) may relate to the county of referral for the participants.  It is noted that the county is fairly affluent and a wide range of services are available to these adolescents. In fact, 77% of the participants were engaged in other services in the three-month period before and after the program.  While concurrent services may often be a reality of those involved in the juvenile justice system, in this particular county the probation controls may have received extensive and high quality rehabilitative services that may not be available in less affluent counties.  Such services may have significantly impacted the results.  In addition, there may be other factors related to the SES level of the community that impact such results as well (e.g., educational and vocational opportunities), perhaps leading again to better outcomes for those who are in the probation program than may be found in other less well-off areas.

Minor and Elrod (1990, 1992, 1994) conducted several studies examining the effects of a three month intervention for juvenile probationers that included job preparation, outdoor experiential programming (three days), and the practice of family skills.  The program was not residential in nature.  Experimental participants were compared to probation controls on self-concept, locus of control, and perceptions of juvenile justice, as well as recidivism at 18-month follow-up.  Participants were classified by previous offense severity as being on “intensive’ probation or “moderate” probation. 

Overall, finding indicated there were no significant differences between the experimental and the control groups on any of the dependent measures or in the area of overall recidivism, either immediately upon completion of the program or at 18- month follow-up.  However, Minor and Elrod (1990) report that it appeared the program may have had some impact on recidivism, noting that “select probationers in the experimental-intensive and the experimental-moderate groups who displayed relatively lengthy criminal backgrounds before the intervention began had significantly fewer criminal offenses over the 18-month follow-up period” (p. 101).   This suggests that such a program may differentially impact individual participants.

Given that it is impossible to examine independently the effects of the adventure component, it is recognized that this is not a scientifically valid finding. As such, further methodological analysis of the data will not be provided.  Of note however, is that the program was non-residential in nature and the adventure component was only three days in duration.  A different format with a longer period of participation in adventure activities may have led to somewhat different results.

 Interestingly however, such a multifaceted intervention could perhaps led itself well to future investigation using component control or additive designs.  Such an investigation need not be limited to delinquent populations.  Not only would this allow for the investigation of potential benefits of using AT as an adjunct treatment, it would also allow for a potential examination of any synergistic effects that may exist when utilizing AT with another form of established intervention.  Such an approach could also potentially circumvent ethical issues that may be involved in utilizing AT as a primary treatment when AT lacks empirical support by allowing for the provision of established treatment as well.  

 

Court Referred Adolescents

            Other studies have utilized adolescents court referred to an AT program as their sample.  Sakofs (1991) examined the effects of a wilderness program on court-referred adolescents. After an extensive screening process, 115 adolescents between the ages of 14-17 were randomly assigned to either a control or an experimental group.  The experimental program was a 24-day wilderness trek, which included a post-completion follow-up of two contacts per month for three months.  The control group, also on probation, engaged in a half day ropes course experience.  Data gathered included self-reports, collateral measures administered to parents,  teachers, and counselors, school and court records, and qualitative analysis.  The assessment measure showed significant positive changes in the area of locus of control, asocial orientation, manifest aggression, values orientation, immaturity, withdrawal, social anxiety, repression,  and peer relations.   The results of the follow-up were unclear, and there were no difference on the behavioral measures between groups.  Sakofs reported that the qualitative analysis revealed further improvements.

            Unfortunately, this analysis also suffers from some of the same inadequacies.  While employing a control group, there are no data available as to the equivalence of such a control group and there are far too many differences among the experiences of the experimental group and the controls to attribute any differences to the treatment alone.  There is no further data available on the participants, nor is there any inclusion of program or therapist variables.  There is also no reliability or validity data available for the measures employed and there is no detailed analysis of the results available.  Thus, there is no basis for a reader to draw informed conclusions beyond those delineated by Sakoffs (1991). Interestingly, it appears that this study may have had some potential for overcoming previously reported methodological inadequacies, however, this is unclear due to the lack of reported detail in his findings.  This is a perfect example of the problems in the AT literature of  “not learning from others mistakes”  (Bandoroff , 1989).

            Wichmann (1991) conducted a somewhat more rigorous study.  Seventy-two “at-risk” males and females between the ages of 13-18 participated in a 30 day wilderness program in groups numbering 8-11.  Of those participants, 90 % were court referred, thus there was a lack of standard random assignment as all court-referred participants were required to participate in the wilderness program.  However, there was an opportunity for a control group offered by an “advocacy program”, which provided a surrogate “big brother or big sister” from the community to spend up to ten hours per week with participant while they waited for the one time per month admission to the program.  This program component was designed as a “holding program for youth who would later participate in a wilderness program” (p. 45).

            Mean age of participants was 14.9 years old, and the sample included 22 participants of both genders (8 male, 14 female). Reported demographics of the control and the experimental groups were similar.  Experience of instructors ranged from 5-15 courses worked and there is no information available as to the clinical training of any such instructors. 

Measures included the Means-End Problem Solving Procedure (MEPS), a self-report standardized measure of interpersonal problem-solving ability, an instructor checklist of expectations for youth-at-risk, and an unpublished checklist of specific asocial behaviors.  While unpublished, Wichmann (1991) did report limited reliability  and validity data for this checklist.  While a seemingly obvious necessity, this again is an improvement from some earlier studies.  Unfortunately, this checklist was completed by the senior instructor of the course at pre and post-testing.  Therefore, it is subject to strong experimenter bias. The checklist measures were given at pre-test and post-test, and the control group was assessed at a similar 25 -day interval.    The MEPS, on the other hand, was only administered to participants one time on day ten of the intervention.  It was unclear as to the rationale behind this discrepancy. 

Using analysis of covariance (ANCOVA) to control for level of asocial behavior at the time of first ratings, the experimental group showed significantly lower levels of asocial behavior upon completion of the program than did the control group.  The control group showed no changes and gender differences were not found.  Regression analyses showed that post-treatment asocial behavior was predicted by pre-asocial behavior, interpersonal problem-solving, instructor experience, and instructor role expectations.  This total model accounts for 61% of the variance in asocial behavior.  The authors note that obviously they cannot control for pre-course asocial behavior, but discuss how perhaps the other variables (e.g., interpersonal problem-solving, instructor experience, and instructor role expectations) show promise for further well-controlled examination.  Unfortunately, there was no analysis of change scores as predictors, a potentially important individual difference variable, and there is no follow-up data available.

This study shows solid attempts at providing an equivalent control group for comparison.  Although the measures used could be improved upon, specifically including more clinically relevant measures and measures with more clearly delineated psychometric properties, the experiment appears to have achieved some of the basic level control necessary to draw some limited conclusions.  Unfortunately, however, there is no program information available and thus we have no basis by which to determine whether or not there was any attempt made at standardization between groups.  In addition, without such information there is no basis by which to determine if the program follows similar procedures as do other programs and thus there can be no basis for generalization. 

A further methodological issue relates to the equivalency of the control group.  Unfortunately, with the current design it is impossible to determine the effects of the advocacy program on controls.  The relationship with the ‘big brother” or “big sister” provided by the program may have had a systematic impact in the individuals in the control group.  Moreover, this impact may have been widely variable across control group participants.  Therefore, this severely limits conclusions that can be made on the comparisons. Additionally, echoing Bandoroff (1989), we cannot be sure as to whether or not change scores simply reflect participant states upon entering and completing the program, and not the effects of the intervention at all.

However, this study does employ more advanced statistical techniques and shows some promise for the technique of examining the impacts of specific process variables on outcome.  Although we can make no determinations as to the long-term impact of such an intervention, the results of this study suggest that there may potentially be an immediate impact of such program. 

 

 

 

Self-Concept

            In another Outward Bound based study, Marsh, Richards, and Barnes (1986) examined changes and stability over time of self-concept for 361 participants ranging in age from 16-31 (mean age= 21) participating in one of ten 26-day Outward Bound programs.  Participants completed the Self-Description Questionnaire (SDQ; Shavelson, Hubner, & Stanton, 1976) which measures 13 differing aspects of self-concept, and the Rotter Locus of Control scale (LOC; Rotter, 1966).  The  SDQ was completed at one month prior to beginning the course (time 1), at the beginning of the course (time 2) and at completion of the program (time 3).  The LOC was completed at time 2 and 3.  The authors report there was no control group provided due to the nature of course participation, and therefore they conceptualize their design as a multiple interrupted time series.

            Results indicated that there were small decreases in self-concept from time 1 to time 2, and these are attributed by Marsh et al. (1986) to pre-course anxiety.  This contradicts earlier findings by Hattie et al. (1997) that found no systematic effects for prior testing,  There were significant increases in all facets of self-concept for time 2 to time 3, as well as significant shifts towards internality on the LOC.  Marsh et al (1997) report that the largest shifts in self-concept were found on the subscales predicted a priori to be theoretically associated with Outward Bound programs.  This is discussed by the authors as providing support for the theoretical basis of such programs.   Comparisons across different programs showed no significant differences in scores on dependent measures.

            This study suffers, however, from the same lack of scientific control extensively delineated previously.  Therefore, such flaws will not be reviewed in detail.  Notably, the lack of a control group provides no basis for comparison and there is no detail provided as to program, participant, or instructor characteristics in order to evaluate standardization across the different Outward Bound programs included in the study. In addition, while extensive analytic techniques were applied to the data, ANOVA models were used primarily in the analysis to examine change in pre-and post-test measures.   Given the lack of a control group it may have been theoretically more useful to employ other techniques (i.e., regression models) in the examination of the data.  Simple analysis of change scores provides limited useful information without a comparison group.

Marsh et al. (1998) are, however, the first to attempt to provide validation at the theoretical level by using a priori predictions.  In addition, their use of a multidimensional self-concept measure examines self-concept in a broader framework; one that can perhaps be applied to future empirical research. Finally, they include an extensive and useful discussion of the possible effects of post-trip euphoria, and provide suggestions for future methodological considerations in this area.  While not specifically relevant to the scientific interpretation of their results, such effects are important to consider in future studies. 

Hazelworth and Wilson (1990) found positive effects on adolescent self-concept, which they report as related to participation in adventure activities, using the Tennessee Self-Concept Scale (TSCS: Fitts, 1964).  However, the severity of the methodological inadequacies in the study, including the lack of a control group, the confounding effects of a general summer camp experience on the adventure component, and a six-day pre-post evaluation period render this study scientifically useless.  In order to avoid redundancy further discussion will not be provided. 

 

Others

            Davis-Berman and Berman (1992) conducted a two-year follow-up study to evaluate stability over time of reported therapeutic gains from a previous study. Originally, Davis-Berman and Berman (1989, cited in Davis-Berman & Berman, 1992) conducted a study of 23 adolescents involved in outpatient psychotherapy who participated in a two- week therapeutically-focused backpacking trip.  During this trip, individual and group psychotherapy were provided on a daily basis by a participating psychologist and individualized treatment plans were followed.  Measures of the dependent variable included pre- and post-test measures of self-esteem, self-efficacy, locus of control, and behavioral symptoms.  Reported findings included significant change in the area of self-esteem, self-efficacy, and behavioral symptomatology.  No further information is provided about this original study.

            The original 23 participants were contacted by mail at four months, one-year, and two- years follow-up.  Standardized measures utilized in the follow-up included the Behavioral Symptoms  Inventory (BSI, Derogatis, 1975), the General Self-Efficacy Inventory (Sherer, Maddux, Mercandante, Prentice-Dunn, Jacobs, & Rogers, 1982), and the Locus of Control Scale (LOC: Rotter, 1966).  In addition, participants were asked to complete a qualitative questionnaire asking about current life situation and any impact of the backpacking experience.  Response rates were 83% at four months and 65% at two years.  Thus, the sample size was quite small and inferential statistics were not conducted. 

            Descriptive statistics showed expected positive results on these measures at post-test.  Interestingly, findings show that negative symptoms on all measures returned somewhat at four month follow-up, but had again dissipated at one year, stabilizing and maintaining after two years (albeit not to post-test levels).  In addition, the qualitative questionnaire revealed that participants felt the trip was a significant life-changing experience. 

Davis-Berman and Berman (1992) discuss how at four month follow-up environmental pressures may have resulted in a return of negative symptoms.  However, they relate the one and two year follow-up to clinically significant change, noting that “over time, changes may become more meaningful and long-lived” (p. 4).  They also discuss how this data highlights the importance of follow-up to help facilitate transfer of changes based on the AT experience to daily life, as such changes are often found to decrease upon completion of this program.

Given the lack of a control group, the small sample size, and the lack of statistical analysis, this study can perhaps be viewed best as a case study.  Therefore, any postulated results are not scientifically generalizable and Davis-Berman and Berman (1992) note that they recommend their study be used to stimulate further exploration of possible trends in this direction. Maturation effects, particularly among adolescents over two years, may have accounted for any reported changes.  Aside from this, this group may have had a unique experience based on any number of factors, both during the intervention and after.  Thus, we can rule out no alternative explanations.  In particular, therapist effects may also have significantly altered the results, as those adolescents who participating in the program were also involved in treatment with the participating psychologist prior to participating in the adventure experience. Thus, the effects of concurrent treatment cannot be ruled out. 

While, as noted above in the theoretical discussion of AT, such a model may have clinical utility, it does not lend itself well to scientific conclusion.  However, similar to the multifaceted program evaluated by Minor and Elrod (1990, 1994), such a program could be used in the future to component control or additive designs.

One final study by Witman (1987) also appeared to add some relevant insight to the literature related to adolescent adventure activities and cooperation and trust.  Witman compared 15-19 year-old adolescents in a psychiatric hospital who were involved in a social recreation group, an adventure-based therapy group, or a control group.  The control group participated in the regularly scheduled program.  The social recreation group and the adventure group each received five additional hours of programming, but the social recreation group participated in sports and games and the adventure group participated in team initiatives and games, trust building exercises, and low ropes course participation.  The leaders for both activity groups were the same and were familiar to both groups prior to the intervention. Sample sizes unfortunately were small, with five controls and six in each treatment condition.  Participants completed a cooperation and trust scale (CATS), measuring both attitudes and behaviors in these domains, and their counselors completed a behavior rating scale focused on trust and cooperation.  Minimal data were available for the reliability and validity of these scales.  These measures were completed pre and post-test for all groups.

Results showed that the adventure group scored significantly higher than both the control group and the social recreation group on measures of cooperation and trust, both self-report and counselor report.  There was no follow-up. 

This study suffers from small sample size and inadequate instrumentation, however it is the first that compared an adventure group to a basic recreation group.  As such, it is the first of its kind that attempted to control for effects due to novelty or simply any sort of active participation in any sort of activities.  While there may be differences in participant variables and therapist effects, it attempts to examine factors previously overlooked.  As such, it suggests that there may perhaps be differences between AT activities and other activities in a similar setting.  It may be worthwhile to include such recreational groups in future design considerations

Once again, this review of the adolescent literature provides us with minimal basis for interpretation of the AT data due to divergent findings and a lack of methodological control.  While it may be that there is some immediate impact of such programs, it is still unclear as to whether such gains are maintained over time.  While the recidivism data presented may be the most interesting data suggesting that there may be an impact of AT programs beyond the immediate post-program testing period, it is clearly mixed with only two studies findings results.  Furthermore, there is also the suggestion found in the literature that AT program may not facilitate lower recidivism rates than does standard probation. In addition, all the studies contain similar methodological flaws.  Therefore, there may be other unexamined factors impacting these results and again these studies are lacking in the control and standardization necessary to make solid conclusions.

Bandoroff (1989) discusses problems with inconsistency in the research, noting that researchers continue to make the same design errors repeatedly.  Instead of “learning from each other’s mistakes” (p 46), he discusses how few researchers attempt to improve on what has been done before, instead often “performing yet another study, each with the purpose of being the definitive study” (p.46). He also discusses problems with standardization and replication, and discusses the difficulties associated with conducting research in a field that is still developing and lacking in a clear theoretical base.

Another important point of critique is the lack of clinically validated and clinically relevant measures in these studies.  There appears to be no studies using any measures of diagnosable pathology or any measures commonly utilized in clinical studies.   Using more appropriate instrumentation, as well as measures that can be linked more clearly to the process and outcome psychotherapy literature, may help to provide some beginning insight into what differentiates the mechanism of change in AT as compared to other treatments.  In addition, this would bring AT one step closer to a place where eventual comparisons with other established treatments can occur.

Given the methodological inadequacies overall and the lack of well-controlled studies, any conclusions in this area are preliminary and further research is necessary to build on these ideas.  It is interesting to note again the wide diversity in programs studied.  This makes meaningful comparisons between such programs impossible and thus there is no generalizability.  Without standardization across programs and increased control over the experimental conditions, the only conclusions we may ever be able to draw are that  some programs may have some immediate impact and some specific programs also may impact recidivism. Specifically regarding such adjudicated adolescents, Bandoroff (1989) asserts that “the field can no longer responsibly assume that any adventure program is good for all delinquents.” (p.56).   Although this seems to contradict his earlier statement supporting of the overall effectiveness of AT with adolescents, it lends support to the idea that any of the results we may find are also limited to the specific program being evaluated and do not generalize to other programs.  Unfortunately, this may be the best that can be said at this point.

 

 

Client Characteristics in Adventure-Based Therapy

            The following section will examine the importance of research into the effects of client characteristics on AT, and then focus specifically on existing research into such characteristics as they relate to outcome in AT.

 

The Need for Client Characteristics Research in Adventure-Based Therapy

Client characteristics and how they relate to outcome is an important topic in the area of psychotherapy research, and findings in the psychotherapy literature may be applicable to AT as well.   Studies suggest that clients who are resistant or reactant may receive less benefit from standard cognitive-behavioral or behavioral treatments and may benefit more from nondirective therapy (Beutler, Engle, Mohr, Daldrup, Bergan, Meredith, & Merry, 1991; Shoham, Bootzin, Rohrbaugh, & Urry ,1995),  Generally, this shows that indeed different types of therapy may be more beneficial for some types of clients than others.  More specifically, it can be speculated that a less directive treatment such as AT may be beneficial for just such resistant clients.  As noted, however, this is purely speculative in nature and no data is available to support such a contention.  Indeed, one might question whether the structure provided by the AT experience might be perceived as directive by some clients.  Process research in AT is necessary to explore such a possibility.

Other relevant psychotherapy studies have shown that hostile clients have increased difficulties in establishing an alliance with a therapist (Arnkoff, Vicotr, & Glass, 1993).  In addition such clients have been found to be less successful in psychodynamic and cognitive-behavioral treatments than other clients (Horowitz, Rosenberg, & Bartholomew, 1993, cited in Castonguay & Schut, 2000). 

Given these findings it is interesting to speculate that there may be individual differences in participants which may have an impact on outcome of the AT treatment for specific individuals. In addition, given the lack of a complete and accepted theoretical base in AT, it may be extremely difficult to establish sound outcome studies in this area without first attempting some additional study into the effect of such basic variables as individual differences in participants and how these may interact with the intervention style (i.e., aptitude x treatment relationship to therapy outcome).  Therefore, one way of starting a preliminary look at process is by examining whether or not client characteristics have any impact on how specific people respond to the treatment, moving out of the realm of process and into the realm of client characteristics which may impact outcome.  Stated another way, does adventure-based therapy affect some people differently than for others?

Focusing on individual differences may also be a way to potentially minimize some of the variance between experimental and control groups.  For instance, if one was able to design a well-controlled experiment in AT, it may be important to know whether certain participant variables may effect whether or not a person is impacted by the treatment.  If an experimenter were to have some idea as to what these factors might be, utilizing such factors as selection criteria would perhaps aid in the establishment of more appropriately selected and tightly controlled experimental groups.  With greater care paid to selection, perhaps there may be more of clear distinction in results

Neill and Richards (1998) suggest this as well, noting that one possible explanation for the wide variability of research results may be related to the nature of the individuals involved in such programs. Ewert (1989) also echoes this idea, discussing the fact that he prefers a change model for adventure-based therapy that includes a consideration of predisposing factors, a model including such variables as personality, propensity for risk-taking, beliefs, and intentions. 

It is certainly possible that different types of individuals respond in a more positive way to adventure-based programs.  It may follow then that if others respond much less positively, the combination of these two groups statistically may result in a moderate effect size (i.e., mean group differences may be eliminated or obscured).  Simplistically put, adventure-based therapy may work for some participants very well and not work at all for others.  McLean and Anderson (1998) echo this statement in a consideration of EST’s for depression, noting that “It has been argued that the modest effect sizes in psychotherapy research are diluted due to mismatches between clients and treatments.” (p. 126).   It follows then that prior to focusing on the overall process, it may be relevant to begin asking the question of “For whom is adventure-based therapy most effective?”

As mentioned much earlier, a simple recognition of the fact that this treatment is increasing in use may justify such an individual difference-based line of questioning prior to the provision of solid empirical support of efficacy.  To explain further, if in fact client characteristics may be impacting outcome, regardless of overall proven treatment effectiveness, this could therefore be important information to bring to bear on those programs which currently use AT as a treatment.  This is not to imply that efficacy studies are unnecessary, rather this statement is provided to highlight the need for such research.  The remainder of this section will focus on the discussion of those studies which have examined client characteristics in AT.

 

Existing Individual Differences Research in Adventure-Based Therapy

Drebing, Willis, and Genet (1987) conducted a study in which they attempted to examine the role of anxiety in impacting the effects of an Outward Bound program (note-while Outward Bound programs have established the model upon which many AT programs have been developed, these program do not actually have stated therapeutic goals and thus do not expressly utilize therapeutic techniques beyond the adventure activities and debriefing).  As noted earlier in the theoretical discussion of AT, anxiety has long been considered an important part of the experiential and therapeutic learning process, both through the element of perceived risk and personal disequlibrium or dissonance.  The important question of interest in this study is of how much anxiety is beneficial. 

Drebing, et al. (1987) note the curvilinear relationship of learning and anxiety; that learning is best facilitated when anxiety is at a moderate level while high levels of anxiety can negatively impact a persons ability to learn effectively and low anxiety can impact a persons motivation.  Thus, they hypothesized that those participants with a moderate anxiety level would be most impacted by their experience and that this moderate level of anxiety would lead to optimal learning.  They also hypothesized that one of the mechanisms by which this increased learning would occur was an enhanced relationship with the leaders and postulated that those with a moderate level of anxiety would be impelled to seek such relationships, while those with high or low anxiety may be less likely to establish such relationships.

Thirty-nine incoming freshman students (27 males and 13 females) were enrolled in a three- week Outward Bound course.  Activities for the course included backpacking, rock climbing, rappelling , and a solo three-day expedition.  Participants were administered the State-trait anxiety inventory (STAI).  While the authors note that there is reliability and validity data available, such data is not presented.  Trait anxiety was believed to be the more relevant of the two in impacting outcome, as the authors felt that this would more accurately reflect an overall propensity towards being anxious instead of situation-based anxiety.  Students were rated as low, medium, or high anxiety based on their scores to the STAI.  

Upon completion of the course, the students were administered a questionnaire rating their satisfaction with the course, perceived  “stressfullness” of the course, perceived level of learning from the course, and their relationships with the leader.  In addition, students were asked about previous experience with the activities of the course (e.g., rock climbing). No information was given as to the characteristics of the leaders, nor is there any further information provided as to program variables or participant variables.  Group leaders also ranked students on performance, level of learning, and the relationship they felt they had established with the student.

The moderate anxiety group showed the highest levels of learning (understanding the meaning of their experience) during the trip, but two days post-completion these differences were no longer significant. Thus the hypothesis that moderate levels of anxiety would lead to the highest levels of learning was generally not supported by students self-reports of perceived learning.  Drebring et al. (1987) note that substantial debriefing and reflection occurred during this two- day period. It may be that this debriefing period facilitated additional understanding for those participants in the high and low anxious group.  This could have implications for further exploration into the impact of such time spent processing after an activity.  Importantly, Drebing et al.’s (1987) use of an ANOVA model as opposed to a regression model reduced their statistical power, thereby increasing the likelihood of Type II error.

Interestingly, the leaders reported that they felt they had established the best relationships with those students of moderate anxiety, but the student ratings showed that as anxiety increased so did their ratings of their relationships with the leader.  For these students it appeared that anxiety and leader relationships had a more direct linear relationship.  Finally, those students with previous experience were significantly less anxious than those with little or no prior experience, a potential moderator of the AT experience to consider in  the future.

It appears from this examination that while the hypotheses of Drebing et al. (1987) were not clearly supported, there were some differences on the outcome measures studied based on differences in anxiety level.  If anxiety is an integral part of the theoretical basis of AT, then this may have implications for individuals who participate in such programs.  This finding regarding the participant’s relationships with the leaders is of note, and further examination is necessary in order to examine factors impacting such important relationships which may be important vehicles for change.  However, the leaders themselves completed the rating forms, and thus there is the potential for bias.  Results such as these may have implied that the leaders simply felt a stronger affinity to those students of moderate anxiety.  One way to circumvent this bias in the future would be to have an objective observer rate these relationships and compare them to the leaders and the student’s ratings.

While there are no definitive conclusions coming for this study about anxiety as a moderator on the effects of adventure experiences, it is a step towards examining the impact of client characteristics on outcome in AT and indicates that such further explanation may prove fruitful.  Designing a well-controlled experiment with a multidimensional assessment of anxiety levels and additional assessment throughout the intervention to determine if perhaps fluctuations in anxiety levels may have further impacted these variables may yield interesting results.  In addition, using a regression model of statistical analysis to examine the effects of anxiety on outcome as opposed to an analysis of variance model would also have improved the statistical power of the study, thus increasing the likelihood of finding existing effects.   

Such a further assessment of the impact of anxiety is important in order to determine if there is potentially an anxiety threshold beyond which such an intervention may in fact be harmful.  Clinically validated measures of anxiety would perhaps be more relevant in making such determinations.  Of note also is that this study was done on a normal population and any results found with such a population may not be generalizable to populations with diagnosable levels of pathology or significant dysfunction.  Once again the caution must be raised, that without such an examination there may be undiscovered potential for harm with such clients.  Further research is necessary into the role of anxiety in AT before such ideas can be fully explored however.  

 Fry and Heubeck (1998) conducted a study looking at the relationship of personality variables and mood states during an Outward Bound course.  Participants completed the Eysenck Personality Questionnaire (EPQ, Eysenck & Eysenck, 1975; cited in Fry & Heubeck, 1998) and were split into high and low groups on the extraversion and neuroticism dimensions.  Of note is that fact that a median split was used to determine these groups and therefore there may be less clear distinctions between groups than could have been found if another method were used  In addition to the EPQ, participants completed the Trait and State version of the Positive Affect and Negative Affect Scales (PANAS; Watson, Clark, and Tellegen, 1988; cited in Fry & Hubeck, 1998) in order to assess for level of positive and negative affect.  The Trait version was used prior to the course and the State version was used during the course

Participants had signed up for a standard Outward Bound course and ranged in age from 16-35 with a mean age of 20.7  Means and standard deviations were reported on all scores, and it was noted that the overall sample mean for extraversion was higher than normative means, while the overall sample mean for neuroticism was lower.  This may reflect a difference in the overall population of self-selected Outward Bound participants.  Such a sample may well be a unique subset of the population, and surprisingly this is the first reported data that suggests such a difference.  This difference may well have impacted the results of this study, as well as the results of additional studies with self-selected individuals engaged in programs of this type.

In order to control for emotionality related to pre-trip tensions, the pre-test ESQ and PANAS measures were given one month prior to the beginning of the course.  The state PANAS was given after the first segment of the trip (day 13), on day two and three of the solo expedition (days 16 and 17), and just prior to the completion of the expedition on day 24.  Given that the goal of this study was not to study outcome, there was no follow-up.  These measures were used to test for levels of positive (PA) and negative (NA) affect.

The program’s effects on mood throughout were significantly different for introverts and extroverts, with extroverts reporting a higher level of positive affect overall.  Interestingly, however, introverts did not conversely report a higher level of negative affect.   As might be expected, differences in state PA were found at different points in the course for both introverts and extroverts, with the lowest level of state PA found during the solo experience.  This is to be expected given that the primary goal at this time is solitary introspection and reflection.

Fry and Heubeck (1998) note that overall levels of state NA were lower during the course than pre-trip levels.   What is most interesting, however, is that there was a greater change from pre-trip level of NA for those participants in the neurotic condition, with the neurotic groups showing the greatest change from pre-test NA at each time of measurement.  While again we have no basis of generalization to a clinical population, this indicates that there may be greater effects for individuals who are more neurotic.  If further exploration revealed support for this supposition, this may ultimately have implications for the use AT with other than normal populations. As of yet, however, this is purely speculative in nature and may simply indicate that neurotics have more negative  affect at the beginning of the course and would return to this negative state upon completion.

This study makes solid attempts to improve on the methodological inadequacies that have come before it and also add a unique contribution to the literature.  Fry and Heubeck (1998) used appropriate statistical analyses in order to answer their questions, and included enough detail in their reporting of the data in order to allow for the reader to make evaluations of the data and not simply rely on what the authors say.  Their preliminary testing of traits at one month prior to the program may have helped to minimize any effects of pre-trip anxiety on the testing.  In addition, they used well-known measures with established psychometric properties.  They also followed a theoretical rationale, both in choosing the measures that they did and in the stating of their hypotheses.  It remains to be seen, however, what may be the implications of their findings.  Finally, one of the biggest improvements was the simple fact that this study was published in a reputable journal.  While this is said somewhat tongue in cheek, it does echo the reality of the AT literature. However, using other than a median split to determine their groups may have been a more valid grouping if the construct of interest is based on high and low levels.

In another study, Neill and Heubeck (1998) examined the effect of an individual’s coping style in an adventure experience, hypothesizing that this style may perhaps be a mediate of the effect.  Participants were Australian 14-15 year old male and female students who attended a nine- day Outward Bound course.  Participants were required to attend the course as part of their school program, therefore in this particular study there was no selection bias present.    The Adolescent Coping Scale (ACS; Frydenberg, 1989; cited in Neill and Heubeck, 1998) was used to assess different coping strategies used by individuals.  There is no reliability and validity data reported for this measure.

  Adolescents in the program reported using productive coping strategies more than the normative data for the instrument indicates is standard for persons of that age.  This would be consistent with the theory of adventure programs; that individuals will be moved outside of their comfort zone and have to rely on more productive coping strategies to negotiate the activities successfully.  It is important to note, however that the outdoor setting restricted such commonly accessible coping activities as drug use, intimate relationships and friendships and traditional sports.  Therefore, they may have chosen to use such coping strategies by default.

Neill and Heubeck (1998) also found that students who reported using more typically non-productive coping skills (i.e., “self-blame”, “worrying”, “ignoring the problem”), received less psychological benefit from an outdoor education program than did those who reported using more positive coping mechanisms (i.e., “positive focus”, “active problem-solving”, “working hard”) (p. 12).   Frustratingly, however, there is no mention of the instrument used to determine “psychological benefit” and therefore there can be no conclusions about such benefits based on this study.  What is suggested, however, is that further research into coping styles, both in the use of alternative coping styles when involved in the program and how these can interact with the program to influence outcome may be necessary.  Although we have no data to support whether or not the use of such positive coping styles existed prior to involvement in the program, nor whether they diminished upon completion of the program, there is evidence presented in previous studies that suggests that program gains may diminish over time.  This suggests that if indeed individuals involved in such a program are utilizing more positive coping mechanisms, future programs should incorporate a follow-up element designed to facilitate and support the continued use of those positive coping styles.  This is speculative, however, as the data does not provide us with any foundation for such statements. 

Generalizability of this study, however, is clearly limited.  The sample is from Australia and there may be cultural differences in attitudes towards such activities between Australia and the US.  The simple fact that such a program is part of a required academic curriculum points towards the fact that there may be differences in such attitudes.  Students know that they will be faced with such a component and therefore may be psychologically prepared in a different manner than are US students.  In addition, the program is only nine days in length as opposed to the standard three week length that most program that have been examined employ.  Therefore, we cannot make adequate comparisons across groups as the activity sequences are of necessity different.

  It may also be that adding this additional two weeks onto the program may have led to differences seen in the patterns of coping.  Nine days is a short enough time for individuals to remain on their best behavior and there may not have been enough opportunity for the students to reach the desired state of disequlibrium.  Also, as it is a required part of the curriculum this may also have led to differences in performance or in accuracy of self-report as the students may have felt they were being evaluated.  Finally, as is noted for all programs that are not expressly therapeutic in nature, any results cannot necessarily be generalized to program that do employ adhere to therapeutic goals.

Other studies discussed in the previous review also examined client characteristic variables.  To highlight, the study conducted by Wichman (1991) discussed previously found that individual differences of clients in interpersonal problem solving behavior, as well as other variables more specifically related to process (e.g., instructor experience predicted 7% of the variance, instructor expectations also predicted 7%) had some impact on asocial behavior of participants upon completion of an adventure program.  Of note in this however is that pre-asocial behavior accounted for the majority of the measured variance (64%) and there was still quite a bit of variance unaccounted for by the measures variables, indicating a large amount of error or overlooked factors impacting those results.  

Kelley and Baer  (1971) and Willman and Chun (1974) also looked found that such client characteristics variables as age of first court appearance, number of parents in the home, age of first institutionalization, and type of offense had an impact on recidivism.  The specific impact is unclear from their results.  It was also unclear whether they looked at these effects across controls and program participants or whether they examined the interaction of program type and these variables.  Such examination may lead to potential insight into how persons with different backgrounds may react differently to such a program.

Hattie et al. (1998) also found differing results based on client characteristics such as age of participant and country of origin.  In addition, they examined the process variable of program length and found that longer programs had greater effects than shorter programs.  Although there were methodological issues with their meta-analysis, this does provide us again with fuel for future explorations. 

Generally, the limited research reviewed here that examines any effects on outcome of individual differences shows some very preliminary results, results upon which we can make no solid conclusions other than that further research is necessary in order to examine the possibilities suggested in this area.

To summarize this research, while overall we may not be able to conclude that anxiety is a specific moderator of experience, it may potentially impact participant relationships with the leaders.  This could have implications for therapeutic programs where such a relationship may be a key factor in facilitating therapeutic change.  We can also see from this review of the client characteristics research that perhaps there may be differences between Outward Bound participants and the general population in the area of extraversion and neuroticism.  This leads to distinct cautions in generalizing any data from such programs, where self-selection is an inherent part of the process, to the general population who may not be interested in such activities.  Interestingly, however, there is some suggestion that it is worthwhile to look at these client characteristics more closely as it is suggested that  persons with high levels of neuroticism may report greater changes on those variables studied. 

We have also seen that outside variables more related to the external environment, such as number of parents in the home, age of first institutionalization, etc. may also impact overall outcome ( i.e., recidivism).  It remains to be seen whether such variables may be a moderating factor of the success of different types of programs for different individuals. As has been noted, however, these conclusions are preliminary and unsubstantiated.  Further research is necessary to make any solid conclusions about any individual difference variables and how they relate to AT outcome.

 

Summary of Adult and Adolescent Outcome Research

 

To review the adult and adolescent outcome research, it appears that based on the quality of the studies examined that the meta-analytic reviews were inconclusive, although if further information was provided as to the quality of studies in Hattie et al’s (1997) review there may be further insight gained.  The only conclusions that can be drawn at this point  are that participant and program characteristics may be a relevant area for further studies and employing designs with follow-up may also yield important information.

Overall, it is suggested that there may be an immediate effect from program participation on self-esteem, depression, anxiety, and trust, while there is contradictory evidence of changes in locus of control.  There is also the possibility that participation in an AT program may increase inpatient discharge rates and time spent in the community for the chronically mentally ill.  What cannot be said is what the impact of the program of an AT program may be for an individual upon leaving the program or how long such effects may last. 

The recidivism data yielded mixed results, and thus we can draw no conclusions from these studies.  What is suggested is that there may be a difference in recidivism between those adolescents who are institutionalized as compared to those who participate in an adventure program, but there may be no differences between adventure program participants and persons who are on standard probation.  Future research is necessary into this important question.  Future designs in this area should attempt to incorporate information as to the environment individuals are released into and the services provided to such individuals upon release in order to assess for the impact of such additional treatments.  Without such information we cannot be sure to what degree any amount of change seen can be attributed to the treatment.

 

Given the overall lack of controlled research in the AT area, as well as the lack of standardization across treatments and programs, the only real definitive statement that can be made from the review of the literature is that any conclusions that can be drawn are based only on the characteristics of the program where the study was conducted and therefore the results cannot be generalized beyond the particular setting.  Unfortunately, overall this leaves us with a body of research with very limited validity, if any, and no generalizability.


Chapter 5

 

METHODOLOGICAL CONSIDERATIONS IN ADVENTURE-BASED THERAPY

 

            This chapter will first focus on a discussion of the methodological considerations in the existing AT research, and compare the existing research to the standards for EST designation.  The second section of this chapter will focus on methodological considerations for future studies, ending with a call for further individual difference based research.  Finally, this chapter will end with a conclusion.

 

 

Present Methodological Considerations

 

As has been shown, the existing AT research employs a wide range of methodologies along with a clear lack of scientific rigor.  Thus, as previously stated, the conclusions and insights which may be gained are seriously limited. The vast majority of studies suffer from severe methodological difficulties, therefore effectively rendering them scientifically useless in the evaluation of adventure-based therapy.  Unfortunately, even the few that attempted to employ an appropriate level of control were still subject to bias, primarily selection bias and bias introduced by the utilization of participant-observers.  In addition, several of the studies remain unpublished and thus are not subjected to a peer review process. 

Gillis (1992) discusses common methodological errors found in the adventure-based therapy research, errors occurring at the most basic level of research design.  Such fundamental design considerations as equivalent control groups, randomization, psychometrically sound outcome measures, clearly defined methodologies, appropriate statistical procedures, and follow-up are often overlooked.  He also notes that many studies utilize quasi-experimental designs and thus the results have limited generalizability. In addition, both settings and treatment methods are diverse, and this also limits the generalizability of results (Kelley, 1993).  Unfortunately, as noted earlier in this analysis there is no clear method of conducting adventure-based therapy (Gillis, 1992) and it seems this confusion is potentially reflected in the research.

Additional overall critiques leveled by Bandoroff  (1989) include the difficulty with selection inherent when utilizing samples that commonly must volunteer for such an experience.  In addition, he urges researchers to consider the need for well-thought out and related variables and measures of interest.  Indeed, when reviewing the literature it seems clear that there are numerous studies utilizing self-esteem and locus of control, but very few utilizing measures of demonstrated clinical utility.   Relatedly, Bandoroff also discusses the need for multi-level assessment and suggests moving away from self-report and more into the realm of objective and behavioral outcome measures. 

Problems associated with the utilization of pre-testing upon arrival at a program are also discussed by Bandoroff (1989), and he notes that upon arrival many participants are angry and resentful, thus perhaps contributing to lower scores on such measures and inflating the change scores.  Such reports may not be representative in an AT program.  In addition, administering post-test measures immediately upon graduation from a program may reflect an inflated sense of accomplishment, a type of “treatment high” that may not reflect the realities of change. 

Bandoroff  (1989) also notes that there is a serious lack of process research (e.g., program variables, instructor variables, participant variables, facilitation variables), and that this may have contributed to the lack of a developed theory of change in the field.  He also discusses the difficulties involved in conducting controlled research in the field and notes how such fluctuating factors as weather conditions and group dynamics may cause even further difficulties.

Herbert (1998) discusses the additional impact of self-selection, noting that self-selection bias may greatly impact results.  In referring to the study he conducted looking at the effects of an adventure program for disabled persons in maintaining supported employment, Herbert notes that there may be important differences between those who did participate and those who chose not to participate.  He concludes that the results may not be generalizable to persons who did not participate, noting that “To what extent results from this study generalize to individuals who do not desire to participate in adventure activities is not known.  Subsequent research may investigate attitudinal, motivational, and/or perceptual differences between persons who participate from those who do not participate in adventure programs.” (p. 17).  This contention lends support to the assertion that there may be important individual differences which impact outcome in adventure-based programs.

Gillis and Thomsen (1996) discuss the difficulties involved with reviewing the research in a field as broad as adventure-based therapy, citing problems in the following areas:  1) language: numerous terms have been used to define what has been commonly referred to as adventure-based therapy, 2) variability:  the process of conducting research in a field this diverse is tremendously difficult, 3)  clinical significance: the issues with regard to moving a client away from a position of pathology to one of health, and 4) clarity:  the field needs to be more clear with what exactly is the process of adventure-based therapy.  Of note is that many of these concerns parallel those in the psychotherapy outcome literature.

This brings us back to the identified criteria necessary to merit classification as an empirically supported treatment ( Chambless & Hollon, 1998). Chambless and Hollon (1998) summarize this process, noting that “we use as our starting point [in the discussion of EST’s] the position that treatment efficacy must be demonstrated in controlled research in which it is reasonable to conclude that benefits observed are due to the effects of the treatment and not to chance or confounding factors such as the passage of time, the effects of psychological assessment, or the presence of different types of clients in the various treatment conditions.” (p. 7). 

It can be seen from the above review that AT does not meet such a criteria.  Well-controlled research is virtually non-existent in the field of AT and without such controls confounding factors cannot be ruled out. In re-examining the EST criteria listed in the beginning of the efficacy section of this paper, one can see that AT does not meet any of the stated criteria.  While it would be repetitive to review all of the ways in which AT does not meet such criteria, it may be informative to compare the AT research to several of the key points embedded in these requirements.

The first most basic design consideration is random assignment, and as has been seen, many of the AT studies do not employ this basic design necessity and often they do not employ appropriate comparison groups.  The second consideration is replication, but without standardization across programs and more tightly controlled samples, such replication may be impossible to achieve.

Other considerations put forth by Chambless and Hollon (1998) are based on sample characteristics and measurement considerations.  They note that it is essential that samples be clearly defined in order to achieve tighter control.  Unfortunately, there is no data available on AT with specific diagnostic groups, and in fact often studies do not report such basic information as sample means and standard deviations on fundamental characteristics such as age  It is important that the research in this area begin assessing pre-participation levels of pathology and other relevant characteristics and make more specific designations of sample characteristics in order to being answering the relevant question of what client is this type of treatment effective for.  .

Chambless and Hollon (1998) also caution that researchers must consider the negative aspects of treatment.  It is an important part of scientific inquiry that research must be approached from a disconfirmatory stance.  In all of the studies reviewed, there was no suggestion of negative impact of treatments, and this subject is rarely broached in the literature.  Without future well-controlled research which remains open to examining potential negative effects of AT, it remains a distinct possibility that such a treatment has the potential for psychological harm.

Finally, Chambless and Hollon (1998) discuss the idea of cost-effectiveness, noting that if there are no differences in outcome, treatments that cost the least are likely to be preferred.  As of this writing, there is no published data available on cost-effectiveness for AT as compared to other treatments. 

Accordingly, AT is nowhere near reaching an EST designation and without concerted and well-controlled efforts in this area, adventure-based therapy is likely to never reach such status.  In this era of managed care, and in the growing context of the movement towards empirical validation of specific treatments for specific disorders, AT as a treatment modality may be shortly extinct except perhaps as a novel treatment modality for those who can afford to pay directly.

Paralleling this lack of EST designation is the contention that psychotherapists have an ethical responsibility to use treatments that work.  While there is plenty of anecdotal evidence in support of AT, there is very little solid empirical data to back up those claims.  As such, therapists using such adventure-based treatments could ultimately be held accountable in presenting a justification for their continued use of such an unproven treatment modality.  Realistically, such a time may not be far off.  Chambless and Hollon (1998), in speaking generally of the need for controlled clinical trials of specific forms of treatment, caution that “the time is rapidly approaching when unsystematic clinical impressions will no longer suffice to document a treatments value, particularly when alternative treatments such as the pharmacotherapies exist that have been subjected to more rigorous empirical scrutiny.” (p. 16).

 It is important, therefore, to consider whether AT may ever show potential for ever establishing proven successful outcomes. Simplistically put, is AT simply a unique entity and perhaps a passing trend?  An examination of potential commonalties between AT and other EST’s may provide further information to inform such a consideration.

   McLean and Anderson (1998) describe several features common to cognitive (CT), behavioral (BT), and interpersonal (IPT)  treatments, all of which have received EST designations for the treatment of depression.  It is encouraging to consider that AT may potentially contain some of these same features.  McLean and Anderson (1998) discuss the commonalties of CT, IPT, and BT treatments being as follows:  The treatment is collaborative, the focus is almost exclusively on present and future, the therapist is active and not passive, there is a high level of treatment structure, there is a development of personal competencies, use of detailed treatment protocols, ongoing empirical assessment, homework assignments used to help facilitate generalization of treatment gains to more naturalist settings, and time limited treatment. 

Referring back to the earlier theoretical description of AT, it can be seen that AT shares many of these same features.  It can be speculated that, based on these similarities, there is the possibility for AT to eventually be proven as efficacious.  To illustrate, in AT the therapist and the client collaborate very much as a team and the focus is primarily on problems that are occurring in the moment, with metaphors used to link these problems to problems which the individuals experience outside of the adventure experience.   The therapist is active in facilitating learning and the transfer of such learning, and there is a high level of structure in the activities, yet the client has responsibility for outcome.  The development of personal competencies is clearly emphasized in AT and the treatment is typically time-limited. While AT clearly falls short in the area of treatment protocols, and ongoing rigorous empirical, these areas are related to questions of methodology as opposed to the potential for therapeutic efficacy. However, it is also important to highlight again that the structure in AT may be perceived as directive by some, a perception which may result in decreased effectiveness for resistant clients (Beutler et al., 1991; Shoham, Bootzin, Rohrbaugh, & Urry ,1995). Process research into the mechanisms of AT is necessary in order to answer such a question. 

Finally, as yet unmentioned, in order to prove itself as an efficacious approach to treatment, AT must prove itself effective in ways that go beyond common factors.  In discussing common factors among different psychotherapeutic orientations, Lambert and Bergin (1994) note that:

“they provide for a cooperative working endeavor in which the patients increased sense of trust, security and safety, along with decreases in tension, threat, and anxiety, leads to changes in conceptualizing his or her problems and ultimately in acting differently by refacing fears, taking risks, and working through problems in interpersonal relationships.” (p164-165).  

 

Clearly, elements of such common factors can be seen throughout AT.  If in fact, AT is identified as containing such common factors, the task for the future is then to prove AT’s efficacy beyond that of other therapies that also contain these common factors. Alternatively,  AT must show itself to be more efficient than such other treatments in accomplishing therapeutic change.  

 

 

Future Directions in Adventure Therapy Research

 

Given the methodological inadequacies in the literature, there are many things necessary in order to begin this process of proving AT to be an efficacious approach to psychotherapy.  This section will first focus on delineating specific considerations for conducting outcome studies in AT utilizing a psychotherapy research framework.  Next, potential for process research will be discussed, and finally a brief articulation of the potential for a future study in the area of client characteristics and outcome will be offered..

 

Outcome Research

            Borkovec (1994) and Kazdin (1992) provide excellent summaries of the important considerations to be recognized when conducting psychotherapy research.   I will briefly discuss several of these points as they relate to research in AT, including some of the difficulties involved in meeting basic controls.  

As with any psychotherapy research, there are significant difficulties involved in considering standardization of the independent variable in AT research. This consideration of standardization is of supreme importance, for as Borkovec (1994) notes “Standardization of procedures across all subjects and the matching of treatment and control conditions on all procedures except the crucial manipulation are ways of holding constant aspects of the environment and the experience of the subjects in that environment.” (p. 249).    Borkovec also notes that “Each of the known and unknown ways in which conditions do, in fact, differ represents a rival hypothesis that could just as likely explain any observed difference.” (p. 249).

There are unique aspects of AT which lead to difficulties with standardization. It is difficult to standardize a treatment while allowing for the flexibility to account for factors such as inclement weather or accidents, and currently we have no assessment of the impact of such factors on outcome. Therefore, manualized approaches may be difficult to implement successfully. 

The changing nature of the outdoor environment also present a difficult challenge in controlling for historical differences across groups.  This may lead to difficulties in comparing and consolidating results of different groups.  While we could hope that large enough sample sizes with the inclusion of multiple groups would randomize such differences, it may be difficult to identify such impacts and such potential differences in history must be considered when determining group equivalence in AT research.

Therapist considerations are another variable all but overlooked in the AT literature.  Borkovec (1994) notes that therapists who participate in treatment outcome studies must be described in terms of background, training and experience.  Any such differences can lead to a diffusion of the treatment.  Presently, differences in training, experience, and techniques utilized by different staff members currently make comparisons across AT programs impossible. In fact, many programs utilize staff that are not formally trained in psychotherapeutic techniques and thus one questions whether such programs are in fact therapeutic in nature.  Such information needs to be presented in AT outcome studies and attempts must be made to hold such factors constant across groups.

Other considerations are related to assessment of the dependent variable. Maturation effects and regression towards the mean are difficult to control for, particularly when conducting research on more long-term AT programs.   Repeated testing may have also have an effect on the dependent variable, and often studies utilize designs where participants are tested on multiple occasions over the length of the program.  Repeated exposure to the instruments may well impact the way participants respond. 

Multiple domain assessment is also necessary.  Borkovec (1994) notes that “multiple measures from different domains of assessment (e.g., cognitive, affective, physiological, and behavioral) and from different methods of assessment (e.g., pre-and post-assessment questionnaires, daily diaries, assessor ratings from interviews, observational measures, significant-other reports, and physiological laboratory assessments) provide more compelling outcome assessment than single domain measurement by a single instrument for the sake of providing converging and valid improvement indices.” (p. 278).  It is obviously necessary to use instruments with proven reliability and validity, as well as clinical and diagnostic utility.  In addition, these measures must be chosen to answer specific theoretically-based questions. 

Dependent measures must also be analyzed using appropriate statistical techniques.  Researchers must be informed of such techniques, and thus be able to make informed choices of particular statistical procedures deigned to answer specific questions of interest.  Relatedly, sample sizes must be big enough to provide enough power to detect group differences.

Another dependent variable consideration is the time of testing.  Often measures are taken just prior to beginning an AT program and immediately upon completion.  AS noted by Bandoroff (1989), such scores may be impacted by pre-trip emotionality or post-trip euphoria and may not be representative of an individual’s normal state.  A better design would be to follow the example of Fry and Huebeck (1998) and administer pre-test measures sometime prior to beginning the treatment.  Post-test measures must then be extended to include follow-up data in order to ascertain the long-term effects of the treatment.  Such follow-up must include information about additional treatment or social services received, as well as the environment an individual enters upon completing the AT program.  There may be largely differential long-term effects for an individual based on these factors, and conclusions about the long-term effects of any treatment cannot be made without information about such potential confounds.  Borkovec (1994) notes that “a thorough follow-up with its relatively small cost is more than just recommendable; it should be required.” (p. 278).

Related to follow-up testing is the consideration of follow-up interventions after completion of an AT program in order to attempt to facilitate maintenance of treatment gains over time.  Herbert (1998) provided the only attempt to empirically examine such a design, however, this attempt was unfortunately unsuccessful due to external circumstances.  This is a consideration worthy of revisiting in the future.

Other dependent variable considerations involve the use of participant-observers as assessors.  In the AT literature, often field staff or therapists who have been actively involved in conducting the treatment are involved in the measurement of participant change.  Unfortunately, such measurement is widely subject to bias based on existing relationships.  In addition, any information that the therapist/staff member has about the participant’s  background, may also potentially introduce bias into the assessment.  Future designs must consider ways to have independent assessors of participant change or utilize more objective indices along with staff ratings.

Borkovec (1994) also refers to clinically significant change, and ways to define such change.  Unfortunately, this discussion may be well beyond the range of the current empirical AT literature.  As has been seen, the vast majority of studies employ such conceptual measures as self-esteem.  When using such inconclusive measurement devices there is no way to define clinical significance and thus there can be no real informed discussion of the topic. 

Borkovec (1994) also discusses design considerations.  Although the lack of sophistication in the AT research precludes such a complete discussion at the present time, it is important to highlight some of Borkovec’s comments on the utility of purely comparative designs in order for researchers to avoid the temptation to compare AT in a simplistic manner to another established therapy.  While it may appear that such designs are the most basic and straightforward avenue to examining the efficacy of AT, Borkovec notes that “Most comparative studies are of such limited value for both applied and theoretical purposes that they should not be conducted” (p. 260), and states that he believes such research to be incapable of providing answers to questions of treatment efficacy due to the lack of validity associated with such designs.  Borkovec discusses the impossibility of holding the clients experience constant across conditions and states that “differential outcome may be due to many, many differences in procedure.  Thus, the investigator’s ability to rule out rival hypotheses is extremely limited.” (p. 260). 

To add to Borkovec’s (1994) comments, in considering a comparison of AT to any other type of psychotherapy which utilizes a standard weekly psychotherapy format, insurmountable confounds are found in considering equivalency of client time spent in therapy.  Even in considering a comparison of AT and inpatient therapy, there are still similar confounds as inpatient therapists do not spend all of their time with the patients.  Major confounds are also inherently associated with the different form of the therapeutic relationship in AT (note-the reader is referred to the previous section on the therapeutic relationship in the discussion of AT as compared to other forms of therapy).

What Borkovec (1994) recommends in place of such comparative designs is an overall approach that goes “deeply into one therapy technique, using increasingly sophisticated designs, methods and measures that explicitly provide basic knowledge about the pathology and the therapeutic change mechanisms of that therapy from which to devise hypotheses about increasingly effective modifications of that therapy (p. 262).  Therefore, instead of simply comparing AT to another type of therapy, it may be important to examine closely the mechanisms of change in AT so that the treatment can be modified if necessary to incorporate the most effective elements of all treatment, both AT and the effective elements of other treatments.

Bandoroff (1989) discusses how researchers can use AT as part of a larger treatment plan and how under these circumstances it is impossible to draw conclusions about the impact of the AT portion of such a treatment (Minor & Elrod, 1990, 1992, 1994).  Of note, however, is that this type of treatment could easily be subjected to a dismantling (component control) approach.  Such an approach would allow for comparisons between those individuals who received the treatment package with the adventure component and those who received the package without adventure activities. Therefore, the dismantling approach could allow for the determination of differential outcomes across components, or between specific components and the overall treatment package.   This approach would also circumvent ethical and methodological issues involved with attempting to provide an equivalent control group.

Relatedly, such an integrative treatment approach could also easily be subjected to evaluation using an additive design in which “two or more therapy techniques are combined into one package” (Borkovec, 1994).  Additive designs also have the same ethical benefits as does the dismantling approach, and both the dismantling and additive designs meet Borkovec’s suggestions for a comprehensive analysis of one treatment as opposed to a direct comparison of treatments  Given the above-noted difficulties in comparing other treatments to AT, it may be more efficacious to approach future AT research by first considering either of these designs.

Borkovec (1994) also discusses methodological issues related to client considerations. While client characteristics may be used as selection criteria, sample characteristics must be also provided in order to allow for an evaluation of generalizability.  Relevant and important information about participants should include information about the severity and duration of the problems they are experiencing and diagnostic information. In order to achieve tighter control in this area, it is important that AT researchers use solid diagnostic tools and outcome measures that tap specific dimensions in identified problem areas. Kelley, Cousey, and Selby (1997) provide the only study to date utilizing clinically relevant measures.

In addition, client attrition rates must be provided and available characteristics of those who atrit must be analyzed separately in order to determine if there are differences.  According to Borkovec (1994), “The important requirements are that all criteria be specified, that they are reliably determined, and that they are based on a valid rationale related to the nature of the disorder and the nature of the questions being asked in the therapy investigation.” (p.271).

Paying attention to considerations such as these may well have a circular effect, for by forcing AT researchers to consider the theoretical basis of the questions that they are asking for the clients that are specified, the results of such inquiry can then be used to potentially expand the theory.  In order for this to occur, AT researchers need to ask themselves such basic questions as “Do we have an identified problem?” and “Are our measures linked specifically to that problem?”  (Chambless & Hollon, 1998).

Borkovec (1994) also notes that it is important to consider the referral source of clients, and that separate analyses of participants from different referral sources may be initially useful in determining if differences in referral sources may be impacting results.  This is particularly relevant for AT participants, who commonly come from such diverse referral sources as mental health providers, schools, justice system referrals, self-referrals, or parents.  Differences in such referral sources may suggest widely diverse client backgrounds.

Finally, there is a need for  discussion of the effect of concurrent or past treatment in AT participants (Borkovec, 1994).  The range of potential referral sources suggest the possibility that at least some of the clients were potentially involved in earlier treatment, or may perhaps be involved in ongoing treatment to which they will return.  Such effects of concurrent or earlier treatment must be evaluated in order to determine the impact of such treatment on any evaluation of the results of AT.  As was earlier discussed, one can speculate that perhaps the best model of all may be one in which a person participates in an adventure-based treatment and then continues in another form of community-based treatment that can build on gains potentially achieved through the AT experience.  As we have no data available to evaluate this model, such remarks are purely speculative at this point.  However, the first step towards building such a model is to begin evaluating potential effects of other treatments on the AT experience.

McLean and Anderson (1998) propose a four step model for psychotherapy research that may provide a useful heuristic for approaching the establishment of empirical support for AT.  The first and second steps involve the establishment of theoretical models in order to propose mechanisms that can be further evaluated empirically.  Proven validity of these mechanisms then allows for the experimental manipulation of the mechanism  in order to compare these mechanisms to other treatments under strict experimental conditions in an attempt to establish efficacy, the third step. Through this ongoing establishment of efficacy, the final step of addressing questions of treatment efficiency can be addressed.  It appears that currently AT research is more in the process of working through the first two steps as opposed to the latter.

Ultimately, these methodological criticisms and considerations involve overarching questions of validity.  Without the implementation of tighter research control, we have neither internal nor external validity, and the best we can say is that some AT programs may have some effects at a particular moment in time with no basis for generalizability.    We must begin tightening controls so that we can find out what works and who it works for so that we can begin to reach some conclusions.

 Without tighter control we will never be able to say definitively that AT is a causal agent of change.  There are currently a seemingly unlimited list of factors, including therapist conditions, standardization, clients considerations, expectancies, placebo effects, contact hours, relationship factors, changes in the environment, novelty effects, post- treatment environmental conditions and many others which could greatly  impact any results that we have seen.  In order to maximize our ability to detect such important relationships as the effect of AT on outcome, we must minimize these threats.  In order to minimize these threats, we must hold such extraneous factors constant across conditions.

While it may appear be a monumental task to take such a large number of factors into consideration when designing and conducting research into AT, it is a necessary step in order to make any conclusions about any type of treatment.  It is possible to accomplish, however, using the best of our accumulated scientific acumen and ability.  To begin, researchers must make every effort to establish the highest level of control possible in their experimental context.   Kazdin (1992) provides researchers with hopeful words of guidance regarding this issue, noting that:

“Ideal methodological practices (e.g. random assignment) are not always available.  Also, restrictions (e.g. a control group may not be feasible, only small sample sizes are available) may limit the researchers options.  In clinical psychology and other related areas of research, the options on methodology, design,  and statistics must be greater to permit the investigator to select and identify creative solutions.  Clinical research is not in any way soft science; indeed the processes involved in clinical research reflect science at its best precisely because of the thinking and methodological ingenuity required to force nature to reveal its secrets.” (p. 8).

 

It also must be noted that the establishment of documented empirical support is a long process, and questions as to the efficacy and change mechanisms of AT will not be answered by one definitive study.

Ultimately, the research in AT needs to start from the beginning, at the most basic level of research design.  Simplistically, the AT research needs to use random assignment, utilize control groups, employ an appropriate level of standardization, create homogeneous groups with large enough sample sizes, engage competent therapists, utilize valid and relevant pre- and post-test measures, and analyze the data in an appropriate fashion.  In addition, should significant change be found, this change needs to be replicated in a different setting.  Should that study be significant as well, to be classified as an empirically supported treatment, two more similar studies with similar findings are required.  Only then will AT be able to claim treatment efficacy.

 

Process Research

            The traditional psychotherapy literature has put a large emphasis on process-related research in the last two decades.  Kazdin (1992) provides a simplistic way of defining process research, noting that the primary question process research tries to answer is “What processes occur in treatment that affect within session performance and may contribute to treatment outcome?” (p. 142).  Castonguay and Schut (2000) contrast process research to outcome research, noting that “Whereas outcome research focuses on whether or not psychotherapy research works, process research investigates how it works (or why it fails to work for everyone). (p. 3).  Ultimately, a process approach moves away from looking strictly at outcome and begins to examine the mechanisms of change in therapy.  Kazdin also notes that “this process research strategy addresses questions pertaining to the mechanisms of change of therapy by addressing manifold concerns of what transpires between the delivery of an interventions and the ultimate impact on the client.” (p. 147). 

There has been very little process research in the area of AT. Such important factors as client and therapist considerations referred to earlier by Borkovec (1994) fall into this realm.  Specifically, Wichmann (1991) found that instructor experience and instructor expectancies somewhat impacted post-treatment asocial behaviors in adolescent participants.  Hattie et al (1997) also found that length of program impacted outcome, with longer programs showing greater results. Other additional process variables of importance in AT could be specific program, therapist, and setting variables.

Kazdin (1992) notes, however, that a line of questioning into process variables is necessarily based on prior studies that demonstrate treatment effectiveness when compared to alternative treatments.  Obviously it has been seen that the AT field is nowhere near demonstrating treatment effectiveness, and in fact, good comparisons of AT with other forms of treatment are non-existent.  Therefore, it may be premature to begin introducing a discussion of process related variables, and a complete discussion of psychotherapy process research and how it relates empirically and methodologically to AT is beyond the scope of this paper.  Following a scientifically-based exploration into AT efficacy, such an area is recognized as being ripe for future exploration.

Castonguay and Schut (2000) provide an excellent summary of the psychotherapy process research. In order to highlight such areas for future AT research, the relevant aspects of this review will be briefly summarized here.  Casonguay and Schut (2000) discuss the goals of process research as 1) to describe the specific processes that occur during therapy, and 2) to identify what factors may impact a clients improvement, either positively or negatively.   In order to accomplish this goal, researchers have attempted to evaluate empirically process variables related to the therapists, the client, the client-therapist relationship, and the structure of treatment.  Of these, the client—therapist relationship has been the most potent predictor of change.  Given this, it is necessary to consider an examination of the impact of this relationship in AT.  As previously mentioned given the potentially unique nature of this relationship in AT settings, such exploration may yield interesting results.

It also must be understood in any consideration of process research that specific factors related to standardization and control in the above methodological discussion of outcome research apply to process research as well.  Therefore, AT researchers must first  move towards establishing basic level scientific control before beginning any valid evaluation of process or outcome.  The challenge of the future for AT research is how to deal with the concurrent issues of establishing such basic level controls while staying within the specific framework of scientific therapy research.

 

Need for Change in the Adventure-Based Therapy Literature

Echoing those concerns of “mainstream” psychotherapy researchers, leading researchers in the AT field have also echoed a need for change in the way AT research is being conducted, and have voiced similar methodological concerns as those above. Gillis and Thomsen (1996) vehemently advocate the need for change in AT research, especially in the face of growing external pressures (e.g., third-party payers), stating  “Do we have any other choice?  Do we risk becoming inert?  Do we deprive those who will benefit most from our services just because we have not done the work needed to make our case known?” (p. 12).

They go on to list several examples of what types of studies need to be conducted, including further meta-analyses, program surveys in order to examine what adventure-based programs are actually doing, an examination of facilitator effects and competencies, and consumer surveys designed to examine what aspects of the interventions that they found most helpful. 

Gillis and Thomsen (1996) also note that in order for the field to begin focusing on what type of intervention works best with which population, the field must more clearly define what exactly adventure-based interventions consist of; including program variables, demographic information, etc. as part of this description.  They assert that without access to this kind of data, clear comparisons between studies and programs themselves are not possible.  Finally, they discuss that it is necessary for the field to attempt to create some sort of homogeneity of method and diagnostic populations to allow for research and program comparisons.  However, as has been noted there are inherent difficulties in involved with the development of such designs due to the dynamic nature of the AT environment. 

Gillis and Thomsen (1996) also provide suggestions as to how to best share information with clinicians in more “mainstream” therapeutic areas, noting that this is important in furthering evaluation of the field.  These suggestions include 1) creating a collective web-based document, 2) close examination of clinically significant events in adventure-based therapy, particularly those with a consumer perspective, 3) communicating the theories and results of adventure-based therapy in the language of mainstream clinicians in order to achieve greater credibility outside of the adventure-based therapy realm, and 4) the continuation of efficacy studies.

To accomplish these goals, Gillis (1992) suggests that what is most essential in the field of adventure-based therapy research is “one clearly defined and researched method of conducting psychotherapy in outdoor learning experiences, in wilderness-adventure settings, or in  adventure-based activities that can be assessed for effectiveness.” (p. 18).  He suggests researchers attempt to do protocol therapy, utilizing specific methods and training manuals, in order to gain the control necessary to truly examine the effectiveness of adventure-based therapy utilizing multiple measures and predictor models.  In addition, he also discusses the necessity of using homogeneous diagnostic populations in order to increase the element of control that can be achieved.

            Han (1997) echoes some of Gillis’ (1992) suggestions, noting that it is important for future research to incorporate a greater level of detail, specifically in regard to the types of activities conducted and definitions of program components.  She also suggested the use of more specific assessments and constructs.

            Bandoroff (1989) maintains that it is important for the field to begin moving away from the same constructs and begin examining other variables. It appears that the field seems to suffer from a lack of new ideas in research, focusing primarily on the same constructs of locus of control, self-esteem, and problem-solving ability.   While established as acceptable outcome measures in adventure-based therapy, these constructs may have been over-examined at the expense of investigating other variables that may be related to outcome.  While having a solid foundation in these areas lends itself well to comparison and replication, it is clearly limiting to continue to examine these same variables in different settings.

            Hattie et al. (1997) also provide suggestions to guide future research.  Many of their suggestions echo those of Gillis and Thomsen (1996), offering such basic design specific recommendations as the use of reliable and valid dependable measures, reasonable sample sizes, and dependent variables related to the outcome of interest.  Also similar to Gillis and Thomsen, they argue for clear documentation of background variables, such as demographic and therapist variables.  They also recommend examining more client characteristic variables, noting that examining variables such as motivations and behavior in outdoor settings, and their interaction can provide us valuable data.  As an additional proposition, they recommend considering alternate research designs, designs moving beyond traditional pre- and post- test designs.   

            Herbert (1998) espouses a need for studies which utilize of follow-up procedures.  He also advocates the use of qualitative research in conjunction with quantitative research in order to understand more about the impact of the AT experience for the individual, noting that the amount learned about participants from their summary scores “paled in comparison to the information one learns about each participant [through an interview]”. (p. 15).  Regarding this issue, he recommends the use of more indirect methods of qualitative analysis, such as the examination of participant’s daily logs.  He notes that such an analysis could provide important and valuable insights into the impact of an adventure-based therapy programs for the individual.  Neill and Richards (1998) also call for the need to understand more about AT from an individual perspective.

            In line with Herbert’s (1998) suggestion as to the need to more completely understand the impact of adventure-based therapy for the individual, Hattie et. al. (1997), Bandoroff (1989), Gillis and Thomsen (1996), and Gillis (1992) all strongly advocate the shift from outcome specific studies to focusing on more process-oriented variables, arguing that future research must examine the relationship of outcome with such process related variables as therapist factors, program elements, and participant characteristics.  This call for process research parallels that of more “mainstream” psychology, with clinical researchers, regardless of setting, asking questions as to what causes client change.   As noted, however, it may be necessary for AT to prove itself as an efficacious approach to treatment prior to such an exploration.  

Related to the shift towards process research is a call for regression techniques to more closely examine client variables which may impact the therapeutic process.  Gillis and Thomsen (1996) also recommend the use of predictor models for future analyses.

            These suggestions, particularly the call for alternative designs, the need to further understand the process of change, the need to understand the impact on the individual, the need to use predictor models, and the need for research on client characteristics and how they relate to outcome lend themselves to the earlier contention that it may be useful to approach future research from a more individual difference- based perspective.  This is also in line with a proposed model for psychotherapy research delineating that theory and mechanisms of change must be established prior to the establishment of treatment efficacy (McLean & Anderson, 1998), a statement that is recognizably a contradiction to an earlier stated contention by Kazdin (1992).   Nevertheless, one way to begin the scientifically rigorous exploration of the therapeutic efficacy and process of AT is to focus on client characteristic variables and their relationship to outcome.

A research approach based on individual difference-based  predictor models may be warranted in order to move towards answering the above proposed question,  “For whom is adventure-based therapy more successful?”, as opposed to “Is adventure-based therapy successful?”

 

 

 

Future Study

To re-visit an earlier contention, it is interesting to consider for a moment the assumption that there may be differential effects of outcome based on client variables.  Should there indeed be a significant effect for such variables, this may have an impact on the interpretation of the results of AT research.  Again the statement potentially may hold true-  if some individuals are greatly impacted and others are not at all impacted, statistically this could impact any analysis of group differences,  thus obscuring the effect of such individual-differences on mean group measures of outcome. It seems to make logical sense then that along with the exploration of  what causes change, we need to begin determining who is most likely to change.  If we can begin to make some empirically-based statements regarding individual differences which impact outcome, we can then include such results in our ongoing consideration of outcome, client characteristics, and process.

One way to begin looking at such variables is offered in the juvenile justice system, where a number of adolescents are court-ordered to participate in adventure-based therapy programs as a result of committing a crime.  Given that these adjudicated individuals have no choice but to participate in such a program (thus eliminating self-selection bias) , a program with court-ordered participants provides a unique laboratory in which to begin to clarify the effects of client characteristics on outcome.  In addition, the utilization of such a sample allows for follow-up data related to recidivism not commonly available in such studies.

            There has been no research to date in the AT literature that has looked at the effect of measured client characteristics on the recidivism rates of juvenile offenders.  Given that it has been suggested that some adventure-based therapy programs may have positive impacts on  recidivism, one logical next step would be to examine the effect of factors which may impact the outcome of such a program at the individual level. 

It is interesting to consider the implications of such a study.  By examining such factors, we may be able to begin developing models which help us to channel individuals more appropriately into the most effective treatments. According to McLean and Anderson (1998) “Treatment matching based on patient attributes promises to provide  better fit between moderators (i.e., client characteristics) and choice of psychotherapy approach.” (p. 126).  Therefore, the examination of client characteristic variables as they relate to outcome in an AT program with court-referred adolescents may be an excellent and useful way to being approaching AT from a more scientific perspective.

This contention will be explored in later document.

           

Conclusion

 

This paper examined the theoretical, clinical, and empirical basis of AT, as well as provided a methodological summary of the present AT research and future directions in AT research.  This analysis is offered in an attempt to provide a foundation for future empirical analysis that can more closely examine the question of whether or not AT can be an efficacious approach to psychotherapy.

As has been seen, AT is a therapeutic modality being used increasingly with a wide variety of populations.  While promoted as an efficacious approach to therapy, when subjected to close scrutiny the empirical data available is unable to support such claims and thus we can make no definitive conclusions about the effectiveness of AT as a treatment, either positive or negative.  Completion of well-controlled research in this area is necessary to help facilitate such conclusions.  For the field to continue to move forward, particularly in a time of increased pressure from HMO’s, government funding agencies, and third-party payees, as well as a growing push towards empirically supported treatments, such efforts are increasingly important and necessary.  In addition, solid empirical research may help to provide a necessary link to traditional psychotherapy, allowing the field to achieve greater attention from “mainstream” clinicians.

At the present time, however, the theories and techniques of this rapidly growing field continue to remain a mystery to most “mainstream” clinicians, and thus this intervention style remains somewhat invisible to those outside of the adventure-based therapy realm.  Indeed, without a solid research base, there is no basis for the field to establish any type of credibility.  Gillis (1992) notes that “adventure-based therapy may need to develop a strong sense of identity and autonomy that is not dependent on others and is yet, at the same time, connected to others in adventure programming or mental health. “ (p. 15). 

It is only through developing a coherent body of research delineating theory,  process, and outcome of adventure-based therapy treatment programs that the AT field can begin to establish credibility and these connections with other mental health professionals.  In fact, it is our ethical responsibility to establish this base in order to justify the continued use of such treatment.  Not only must we build a body of empirical data that allows us to make determinations about the efficacy of this treatment for particular populations, we must also conduct research with an eye to those for whom it may be harmful.  On a more pragmatic side, if researchers are able to establish AT as an efficacious approach to therapy, there are additional benefits potentially available such as increased referrals and third-party payment.  In the current mental health climate related to managed care, this is a very important consideration.

One important piece of this process is research focusing on client characteristics that may impact outcome.  By focusing on the preliminary question of “For whom is adventure-based therapy most successful?”, we can start developing models that allow us to begin concentrating on other issues related to the establishment of empirical support for AT.  Questions such as this are not specific to adventure-based therapy alone, rather they are questions that all clinicians and researchers need to be asking with regard to intervention, including such issues as “what type of treatment is most effective for whom under what circumstances?”  Perhaps by beginning to answer such questions, researchers in the area of adventure-based therapy can add a potentially unique contribution to the vital question of what it is that helps people to change.


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