Psychotherapy Brown Bag

Guest article - Wilderness therapy: A popular but misguided treatment for "at risk" adolescents

by Kim Van Orden, Ph.D.

Adolescence is a time when some degree of emotional dysregulation is normative, and it is also the case that some adolescents demonstrate emotional and behavioral dysregulation in excess of what is normative that places them at risk for outcomes such as suicidal behavior, drug abuse, sexually transmitted diseases, and school drop-out (e.g., Miller, Rathus, & Linehan, 2007). Understandably, parents often feel desperate to help their teenagers when risky behaviors come to their attention. My job as a clinical psychology intern last year gave me the opportunity to work as a therapist with suicidal adolescents and their parents. Many of these parents and teens entered the treatment program hopeless that psychotherapy could help them make important changes in their lives – the problems seemed too “big” for the skills we had to offer. After all, teens spend most of their time at school, at home, or with their friends. Thus, understandably, parents sometimes look to treatment approaches that involve taking their teens out of their stressful environments.  Before sitting down to write this article, I tried searching the internet for “troubled teen” and some of the top hits were “wilderness therapy” programs –these are the resources many parents may first explore when looking for help for their teen, and as these programs involve taking the teen away from their current stressors, they may seem appealing.  In addition to my training as a cognitive-behavioral therapist and suicide researcher, I also spent a year working at a non-traditional therapeutic community in the beautiful green mountains of Vermont. Thus, my first reaction to wilderness therapy programs was interest and intrigue. However, my training in empirically supported treatments led me to read the scientific literature before forming an opinion—and in this article, I’ll share with you what I found in my search. To start, I provide a brief overview of wilderness therapy programs, including the lack of evidence for their effectiveness for “at risk” youth. I conclude with a discussion of empirically supported treatment programs for youth demonstrating impulsive and risky behaviors.

The definition of wilderness therapy varies depending on who is writing the definition. The Government Accountability Office used the term “residential treatment programs for troubled youth” and defined these programs as ones that “…provide a range of services, including drug and alcohol treatment, confidence building, military-style discipline, and psychological counseling for illnesses such as depression and attention deficit disorder” (Kutz, & O’Connell, 2007).  They defined wilderness therapy specifically as one such program “that places youth in different natural environments, including forests, mountains, and deserts.” The Government Accountability Office noted that the programs may market themselves as “… wilderness therapy programs, boarding schools, academies, behavioral modification facilities, and boot camps, among other names.”

In contrast, the National Association of Therapeutic Schools and Programs defines these programs in the following way: “Outdoor behavioral health programs apply wilderness therapy in the field, which contains the following key elements that distinguish it from other approaches found to be effective in working with adolescents: 1) the promotion of self-efficacy and personal autonomy through task accomplishment, 2) a restructuring of the therapist-client relationship through group and communal living facilitated by natural consequences, and 3) the promotion of a therapeutic social group that is inherent in outdoor living arrangements.”

Consistent with the mission described above, a meta-analytic review indicates that outdoor adventure education programs (e.g., Outward Bound), appear to be effective in terms of increasing confidence, self-efficacy, self-understanding, assertiveness, internal locus of control, and decision-making – and these improvements appear to be maintained over time (Hattie, Marsh, Neill, & Richards, 1997). It is important to note that there is a distinction between the experiential education programs run by schools such as Outward Bound and the National Outdoor Leadership School (NOLS) and wilderness therapy. Wilderness therapy programs involve tailoring these types of experiential education programs—purportedly—for at risk youth. While the data support positive outcomes in terms of  self-efficacy and fostering of other such personal strengths through outdoor experiential education, there is not a single published randomized-controlled trial investigating the efficacy of these programs in the treatment of mental disorders, or the prevention of “risky” behaviors, such as drug use, that these programs are purportedly designed to prevent.

The lack of evidence for these programs is especially concerning given that youth have been abused and have died in these wilderness therapy programs, according to a report by the Government Accountability Office (2007; the report can be accessed online at the GAO website; http://www.gao.gov/). Wilderness therapy programs are currently not overseen or regulated by the federal government and some states do not require licensure. As one step towards regulation, the Bureau of Land Management issued a memo in June, 2008 indicating that permits will not be renewed for agencies that do not have documentation of state licensure.  

The GAO conducted an investigation of 10 cases in which teenagers died during these programs and concluded that three factors were common to the programs of these youth: 1) untrained staff (e.g., staff attributed youth behavior to “faking it” rather than physical illness), 2) inadequate nourishment of youth (e.g., forced fasting); 3) reckless or negligent operating practices (e.g., not bringing radios; guides unfamiliar with the area to be hiked). The report includes details of how these youth died, including one youth who was restrained by staff and held face down in the dirt for 45 minutes; this youth died of a severed artery and his death was ruled a homicide by the courts.  Thus, data indicates that wilderness therapy programs for “at risk” youth can be dangerous, even lethal. However, empirical studies have demonstrated that there are effective treatments for adolescent impulsive and risky behaviors, including suicidal behaviors.

Dialectical Behavior Therapy (DBT; Linehan, 1993) is a cognitive-behavioral therapy designed to treat emotion regulation difficulties and suicidal behavior and is the only treatment shown to effectively treat suicidal behaviors in more than one randomized controlled trial. A modification of DBT for adolescents with suicidal behaviors (and other impulsive, risky behaviors) has been developed and a book describing the treatment is available (Miller, Rathus, & Linehan, 2007). The adolescent modification includes families in treatment, including multi-family skills training and family sessions, and also includes a skills training module developed specifically for teens and their families called, “Walking the Middle Path.”  Initial data using a quasi-experimental design examining the effectiveness of the treatment in reducing suicidal behavior are promising (Rathus & Miller, 2002).

Multisystemic Therapy (MST) is an intensive community based treatment for youth (Henggeler, Schoenwald, Rowland, & Cunningham, 2002). The treatment was originally designed to treat youth antisocial behavior and has also been adapted for emotional and behavioral dysregulation that places youth at risk for out-of-home placements (e.g., psychiatric hospitals); a detailed manual is also available for this purpose. A primary goal of MST is to help families alter the social contexts of their teens to make the contexts supportive of healthy behaviors and non-supportive of unhealthy behaviors (e.g., helping youth disengage from connections with deviant peers and fostering connections with prosocial peers). MST therapists work hard to connect with families—and stay connected: they conduct therapy sessions in the home, school, or other places in the community. One particularly impressive RCT of MST showed that MST was more effective than hospitalization at reducing suicide attempts at a one-year follow-up (Huey et al., 2004).

As a proud Outward Bound alumni, I am a strong believer in the benefits of spending time in the wilderness for personal growth. Results of empirical studies suggest that wilderness programs are appropriate – and beneficial – for just that – personal growth, not the treatment or prevention of serious mental illness in youth (or adults). There is clear evidence that young people have died and that these deaths were a direct result of participation in wilderness therapy programs. In contrast, empirical studies support both Dialectical Behavior Therapy and Multisystemic Therapy in the treatment and prevention of adolescent impulsive and risky behaviors. Instead of removing teens from their environments, as with wilderness therapy, DBT and MST therapists are out in the trenches with teens and families in their own environments -- a strategy that works and saves the lives of teens.

For More Information

For more information on DBT, including training, see the Behavioral Tech website:
http://behavioraltech.org/

For more information on MST, including training, see the MST website:
http://www.mstservices.com/

Additionally, for resources on DBT or MST, Psychotherapy Brown Bag suggests the following books, all of which are available through the online store of science-based psychological resources:

MST:

Multisystemic Treatment of Antisocial Behavior in Children and Adolescents by Scott Henggeler, Sonja Schoenwald, Charles Borduin, Melisa Rowlad, and Philippe Cunningham

DBT:

Dialectical Behavior Therapy with Suicidal Adolescents by Alec Miller, Jill Rathus, and Marsha Linehan

Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha Linehan

Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan

Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings by Linda Dimeff, Kelly Koerner, and Marsha Linehan

Dialectical Behavior Therapy for Binge Eating and Bulimia by Debra Safer, Christy Telch, and Eunice Chen

Kim Van Orden is a post-doctoral fellow at the Center for the Study and Prevention of Suicide, University of Rochester Medical Center

The Quality and Content of Supervision Leads to Long-Term Benefits for Clients - October 2009 Psychotherapy Brown Bag Featured Article

by Kelly Cukrowicz, Ph.D.

My name is Kelly Cukrowicz and I am an Assistant Professor at Texas Tech University. My research focuses generally on emotional and interpersonal correlates of suicide ideation in older adults, as well as longitudinal predictors of change in suicide ideation. Instead of contributing a piece in this area, I’d like to focus on the topic of supervision. Being a supervisor is an important role for me and one that I really enjoy. I take pride in being able to assist graduate student therapists in their growth as therapists, as well as in sharing information with them about empirically supported treatments. This semester my supervision team is reading articles on this topic and gaining experience offering supervision within student dyads.

As such, I’ve given a lot of thought recently to questions such as, “What makes good supervision?” and “How do differences in supervision impact treatment implementation and outcomes?” The literature has provided us with more information pertinent to the first question, so I’ll focus here on the second one. Basically, what impact does supervision have on the client, through (presumably) increased skill in treatment delivery of the therapist? In 2005 I was the lead author on a manuscript that examined the impact of a shift to empirically supported treatments on client outcomes at the Florida State University Psychology Clinic (Cukrowicz, White, Reitzel, Burns, Driscoll, Kemper, & Joiner, 2005). This article was discussed previously on PBB, so I won’t repeat the details. The gist of the study was that requiring training and supervision on empirically supported treatments drastically improved client outcomes. 

A recent study published in Journal of Clinical and Consulting Psychology has also examined the impact of clinical supervision on treatment outcomes. Schoenwald, Sheidow, and Chapman (2009) examined the relations between clinical supervision, therapist adherence to the treatment protocol, and changes in youth behavior and functioning problems one-year post treatment in a sample of youth with serious antisocial behavior problems. In a review of the literature on this topic, the authors point out that some existing studies have examined the impact of supervision on client outcomes for trainees; however, there is a dearth of research examining whether supervision impacts treatment adherence and client outcomes in usual care settings.

Schoenwald et al. examined data from a National Institute of Mental Health-funded study on practice context factors that may impact the implementation and client outcomes for multisystemic therapy (MST). The authors predicted that therapist adherence would mediate the impact of supervisor adherence on outcomes over this one-year period. The participants in this study included 1,888 families, 429 therapists, and 122 supervisors. This intensive treatment (see Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 1998) averaged 22.2 weeks for this sample and included a typical caseload of four to six families (youth and caregiver) per therapist. Treatment length averaged four to six months depending on the needs of the family. Supervision was offered to teams of three to four therapists by supervisors who devoted at least half of their time to offering supervision and obtaining consultation from experts in this treatment.

Therapist adherence to the treatment was assessed monthly via caregiver ratings on the MST Therapist Adherence Measure – Revised (TAM-R). This 28-item scale allows caregivers to rate therapist adherence to the nine principles of MST. Supervisor adherence was assessed via the Supervisor Adherence Measure (SAM), on which therapists rate their supervisor every two months.

Mixed effects regression models were used to test the primary prediction indicated above. The results of this study indicated that two of the four dimensions of MST supervision predicted one-year outcomes for youth behavior. These dimensions were adherence to structure and process and focus on clinician development. Another dimension, adherence to principles, predicted therapist adherence to the treatment protocol. Further, therapist adherence ratings completed by the caregiver were associated with reduction in youth behavior problems over the one-year time period. Due to a lack of support for the initial prediction that supervisor adherence would impact both therapist adherence and youth outcomes, the mediational model was not tested.

Taken together, the results of this study suggest that some aspects of the supervision process may be more important than others in their association with therapist adherence and client outcomes. In this study, adherence to the principles of the treatment by the supervisor was most important. This subscale assesses the extent to which the focus of supervision was on the consistent assessment and therapeutic principles of MST. Thus, the therapist’s actions in therapy that are observable to caregivers (and subsequently can be rated on the TAM-R) are most prominent. As such, it may be that this factor appeared most important in part due to the fact that it was easier to rate. It is interesting to note that this dimension was most associated with therapist adherence, but not to one-year outcomes in youth behavior. The most important dimensions of supervision for youth outcomes were adherence to structure and process and clinician development, suggesting that supervisory efforts to teach the specific skills of MST and to ensure that the therapist’s goals, skills, and competencies were addressed had the greatest impact of youth behavior outcomes.

The results of this study are very encouraging to me as a supervisor. This study finds that important elements of the supervision process impact not only therapist adherence to the treatment, but also client outcomes. This study did not find any factor that was jointly associated with both; however, it does suggest that high-quality supervision does have a strong impact on both the delivery of services, as well as the benefits experiences by clients. An incredibly important element of this study was the long-term nature of the follow-up period. It isn’t just that high quality supervision has short-term benefits for clients – it actually yields effects that are maintained a full year later. When significant psychopathology is the focus, as in this study, this is incredibly important.

As I consider how all this applies to my own work as a supervisor, I am reminded of just how important it is to stress the need to “stick to it” with regard to continued use of the techniques, principles, and associated assessment principles associated with the selected treatment.

If you would like to learn more about empirically supported treatments for mental illness in general or multisystemic therapy in particular, Psychotherapy Brown Bag recommends the following products, all of which are available through the site's online store:

• A Guide to Treatments that Work by Peter Nathan and Jack Gorman

• Science and Pseudoscience in Clinical Psychology by Scott Lilienfeld, Steven Lynn, and Jeffrey Lohr

• Clinical Handbook of Psychological Disorders, Fourth Edition: A Step-by-Step Treatment Manual by David Barlow
  

• Multisystemic Treatment of Antisocial Behavior in Children and Adolescents by Scott Henggeler, Sonja Schoenwald, Charles Borduin, Melissa Rowland, and Phillippe Cunningham

Kelly Cukrowicz is an assistant professor of psychology at Texas Tech University