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Explaining therapeutic change in residential wilderness therapy groups

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Gillis, H. L., & Russell, K. C. (2017, February). Explaining therapeutic change in residential wilderness therapy groups. [Web article]. Retrieved from: http://www.societyforpsychotherapy.org/explaining-therapeutic-change-in-residential-wilderness-therapy-groups

Dr. Lee Gillis

Residential wilderness therapy or adventure therapy is “the prescriptive use of adventure experiences provided by mental health professionals, often conducted in natural settings that kinesthetically engage clients on cognitive, affective, and behavioral levels.” (Gass, Gillis & Russell, 2012 p.1).  The term adventure therapy is used in the literature interchangeably with “wilderness therapy” (Russell, 2001) and “outdoor behavioral healthcare (OBH)” (Russell & Hendee, 2000).  All these terms refer to treatment that takes place with small groups often in outdoor settings utilizing either short (1-5 days) forays into nature or extended expeditions (14-60 days) where participants are immersed in a wilderness setting. White’s (2015) history of the field points to an evolutionary tree for adventure therapy whose DNA includes therapeutic summer camps, Boy Scouts, Outward Bound, and even The Church of Jesus Christ of Latter-day Saints.  The recorded history of this therapeutic intervention dates back to 1861.

Dr. Keith Russell

How does Outdoor Behavioral Healthcare look in practice?

Therapeutic outdoor experiences typically occur in small groups (4-8 clients). Most of the groups are “open” with clients entering and leaving as they go through intake or discharge; it is rare these days to have a cohort of clients who go through a whole program together.  Thus, the group climate can be in constant flux and how congruent a member’s perceptions are with the rest of the group has been found to have implications for treatment progress. At least that is the premise put forth in the Gillis, Kivlighan, & Russell (2016) manuscript in volume 53 of Psychotherapy.

Dr. Gillis (left) & Dr. Russell (right)

Theoretically, the OBH group therapy that takes place has the members’ shared experience(s) of paddling, hiking, rock climbing, etc. on which to reflect and give feedback to one another.  Individuals set therapeutic intentions prior to an outing and project when they may have opportunities to engage in that intention.  For example, prior to a recent river crossing, one group member, based on his past history with the group, wanted to step up and take the lead with his peers as he had been sitting back and letting others take charge in previous activities.  He projected that once they arrive at the river would be his first opportunity to step forward.  Conversely, another group member stated his therapeutic intention was to stay quiet and listen to others as he had previously blurted out what he was thinking with little regard for what other group members wanted to do.  In each case the group members offered suggestions to clarify the intentions and question how they might see it realized.  The intentions are written down in the group room and then used as the basis for feedback in the group session following the experience.

Many of us who embrace this particular experiential approach find a strong foundation in principles of Gestalt Therapy, Psychodrama, and Carl Rogers’ Person Centered groups while grounding ourselves in evidence based cognitive behavioral approaches to treatment.  The conscious and intentional use of metaphor (Bacon, 1983; Gass, 1991), influenced by Milton Erickson’s work, is also prominent among many adventure therapists.  For example, the river crossing mentioned above provides numerous therapeutic metaphors to discuss in a group session whether they be being mindful of how one steps forward in life when the footing is unsteady or simply the challenges of getting from one place to another (one side of the river to the other).

Making sense of the adventure therapy group climate black box

The metaphor of a “black box” (Ashby, 1956) is often used when trying to make inferences about how change takes place within a program when examining only inputs (pretests) and outputs (posttests). Positive pre to post treatment changes in client progress as measured by the Outcome Questionnaire 45.2 (OQ 45.2) (Lambert & Finch, 1999) and Youth Outcome Questionnaire 2.0 SR (YOQ 2.0 SR) (Bulingame, et al 1996) during adventure therapy experiences for adolescents and young adults has been well documented (c.f., Bettmann et al., 2016, Gillis, et al. 2016, Norton et al, 2014). Meta-analyses have consistently demonstrated moderate (d = 0.45) effect sizes for adventure therapy (c.f., Bowen, Neill & Crisp, 2016; Cason & Gillis, 1994).

Russell, Gillis, & Heppner (2016) recently found that changes in the non-reactive factor of trait mindfulness (Baer, et al., 2008) helped explain OQ 45.2 change in young adults being treated for substance use disorder in an OBH program despite the program studied not having formal mindfulness training.  The authors posited adventure therapy as a mindfulness-based experience (MBE) especially when involved in reflecting on their excursions into the wilderness with explicitly stated therapeutic goals to achieve while out on trail.

The global changes in the non-reactive mindfulness factor among clients does not examine how engagement in the group experience influences outcome.  That was the purpose of the Gillis et al. (2016) manuscript in volume 53 of Psychotherapy. We examined how other member and person context moderate the relationship between group members’ perceptions of engagement and their treatment outcome using the actor partner interdependence model (APIM).

When the other group members generally see the group climate as engaged, higher general perceptions of engagement for the member are related to fewer depression and anxiety symptoms, clarity of social roles and interpersonal relationships.

When the other group members generally see the climate as not engaged, higher general perceptions of engagement for the member are related to more problems.

When the group member generally sees the climate as engaged, higher member biweekly perceptions of engagement related to fewer problems during that 2-week period.

When the member generally sees the climate as not engaged, higher biweekly perceptions of engagement for the member are unrelated to changes in problems.

Summary and Conclusions

In essence, this research is highlighting the role that congruence in member, group, and leader perceptions play in effectuating treatment outcome. When these perceptions become misaligned, individual client well-being can be affected, which in turn could create a cascading effect, leading to isolation and withdrawal from the group, thus affecting overall group engagement.  Monitoring these perceptions of engagement in conjunction with progress monitoring is warranted.  Practical implications for group therapists are to routinely monitor how group members view the group climate.

In this article we used the five item engagement subscale of MacKenzie’s (1983) Group Climate Questionnaire. We have recently switched to the Group Questionnaire available at oqmeasures.com in an attempt to examine how the three factor structure (positive bonding, positive working, and negative relationship) might provide more information to both therapist and to group members when used in progress monitoring. We will continue to examine the effects that bonding and working relationships has on treatment outcome both in the moment and during the weeks prior to group and community meetings because of our preliminary findings.

Finally, as authors, we are deeply indebted to Dr. Dennis Kivlighan for the APIM analysis and mentorship with the statistics!

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References

Ashby, W. R. (1956). An introduction to cybernetics. An introduction to cybernetics. London: Chapman & Hall Ltd

Bacon, S. B. (1983). The conscious use of metaphor in Outward Bound. Denver, CO: Colorado Outward Bound School

Baer, R. A., Smith, G. T., Lykins, E., Button, D., Krietemeyer, J., Sauer, S., Walsh, E., Duggan, D., & Williams, J. M. G. (2008). Construct validity of the Five Facet Mindfulness Questionnaire in meditating and no meditating samples. Assessment, 15(3), 329-342.

Bettmann, J. E., Gillis, H. L., Speelman, E. A., Parry, K. J., & Case, J. M. (2016). A meta-analysis of wilderness therapy outcomes for private pay clients. Journal of Child and Family Studies, 1-15.

Bowen, D. J., Neill, J. T., & Crisp, S. J. (2016). Wilderness adventure therapy effects on the mental health of youth participants. Evaluation and Program Planning, 58, 49-49.

Burlingame, G. M., Wells, M. G., Hoag, M. J., Hope, C. A., Nebeker, R. S., Konkel, K., McCollam, P., & Reisenger, C.W. (1996). Manual for youth outcome questionnaire (Y-OQ). Stevenson, MD: American Professional Credentialing Services.

Cason, D. & Gillis, H.L. (1994). A meta-analysis of outdoor adventure programming with adolescents. Journal of Experiential Education17(1), 40-47.

Gass, M. A., Gillis, H. L., & Russell, K. C. (2012). Adventure therapy: Theory, practice, & research. NY: Routledge Publishing Company

Gass, M. A. (1991). Enhancing metaphor development in adventure therapy programs. Journal of Experiential Education14(2), 6-13.

Gillis Jr, H. L., Speelman, E., Linville, N., Bailey, E., Kalle, A., Oglesbee, N.,Sandlin, J., Thompson, L., & Jensen, J. (2016). Meta-analysis of treatment outcomes measured by the Y-OQ and Y-OQ-SR comparing wilderness and non-wilderness treatment programs. Child & Youth Care Forum, 45, 851-863

Gillis, H. L. (L.), Jr., Kivlighan, D. M., Jr., & Russell, K. C. (2016). Between-client and within-client engagement and outcome in a residential wilderness treatment group: An actor partner interdependence analysis. Psychotherapy, 53(4), 413-423. http://dx.doi.org/10.1037/pst0000047

Lambert, M. J., & Finch, A. E. (1999). The Outcome Questionnaire. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcomes assessment (2nd ed.) (pp. 831-869). Mahwah, NJ: Lawrence Erlbaum Associates.

MacKenzie, K. R. (1983). The clinical application of a group climate measure. In R. R. Dies & K. R. MacKenzie (Eds.), Advances in group psychotherapy: Integrating research and practice (pp. 159–170). Madison, CT: International Universities Press.

Norton, C. L., Tucker, A., Russell, K. C., Bettmann, J. E., Gass, M. A., Gillis, H. L., & Behrens, E. (2014). Adventure therapy with youth. Journal of Experiential Education37(1), 46-59.

Russell, Keith C. (2001). What is wilderness therapy? Journal of Experiential Education, 24(2) 70-79.

Russell, K. C., Gillis, H. L., & Heppner, W. (2016). An examination of mindfulness-based experiences through adventure in substance use disorder treatment for young adult males: A pilot study. Mindfulness, 7(2), 320-328.

Russell, K. C., & Hendee, J. C. (2000). Outdoor behavioral healthcare: Definitions, common practice, expected outcomes, and a nationwide survey of programs. Idaho Forest, Wildlife, and Range Experiment Station.

White, W. (2015). Stories from the field: A history of wilderness therapy.  Wilderness Publishers.

 

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