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:
For more information on MST, including training, see the MST website:
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:
Multisystemic Treatment of Antisocial Behavior in Children and Adolescents
by Scott Henggeler, Sonja Schoenwald, Charles Borduin, Melisa Rowlad, and Philippe Cunningham
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