Outdoor Adventure Interventions - Young People and Adversity: A Literature Review

Prepared for Berry Street by: Dr Anita Pryor with assistance from Reima Pryor & Dr Cathryn Carpenter Adventure Works Australia Ltd ISBN: 978-0-6482088-1-5

© Berry Street Victoria Inc., 2018 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any person without prior written permission from Berry Street Victoria. It may be reproduced and used by licensees, in whole or part, subject to acknowledgement of the source but not for commercial usage or sale. Requests and inquiries concerning reproduction rights should be addressed to: Director, Berry Street Childhood Institute 1 Salisbury Street, Richmond VIC 3121 1800 2377 978 [email protected] www.childhoodinstitute.org.au

ii Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Outdoor Adventure Intervention Recipe

Select: 8-12 people who are ready for an adventure Stir: a sense of anticipation Add: a few skilled practitioners Remove: social and emotional dependencies (friends, family, tobacco, alcohol, flushing toilet, phone) Place: in a wild environment Mix: until a team starts to form Fill: with unusual and exciting experiences Stir in: responsibility for self and others Watch: to see that all are fully immersed Add: the opportunity to learn and master skills Sprinkle: moments of awe and beauty Simmer: carefully for many days and nights Prepare: for going home Invite: participants to reflect on their experiences Take: lessons learned and hopes revealed Serve: when ready1.

1 Adapted from Pritchard, D. (Date unknown). Outward Bound Recipe, Minnesota Outward Bound School. Retrieved 10 Oct 2017 from: http://www.wilderdom.com/outwardbound/obmain.html

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review iii Table of Contents

Glossary vii Executive Summary 1 1. Introduction 4 Background 4 Guiding questions 5 Methods used 5 Search strategy 7 Literature evidence base 7 Terminology and working definitions used in this report 8 2. Young people who have experienced adversities 10 Needs of target group 10 Evidence on effective interventions with this target group 11 Trauma-responsive OAI 14 Evidence-informed OAI in support of this target group 16 3. Outdoor adventure interventions 18 Spectrum of interventions 19 Readiness for change 21 Depth of intervention 21 Intensity of experience 22 Therapeutic intent 23 Paradigms of practice 24 Typology of Australian OAI 26 Comprehensive safetynet 28 Ethical principles 29 International perspectives 30 4. What the literature says 32 Current uses of OAI with this target group 32 Outcomes for young people 35 Known benefits for young people generally 35 Likely benefits for young people who have experienced adversities 38 Likely longitudinal benefits for young people who have experienced adversities 44 Mechanisms of change 47 Examples of effective OAI 52 Ineffective and negative outcomes 55 5. What works 60 Responding to history and heritage 60 Staff values, skills, approaches and self awareness 62 Program design 70 A note on limitations 83

iv Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 6. Key messages 85 Bibliography 88 Appendices 100 Appendix 1: Recommended Reading 100 Appendix 2. Important Considerations for this Target Group 101 Appendix 3: OAI Principles Aligned with AABAT Ethical Principles 104 Appendix 4: Secondary Literature Review Search Strategy 108 List of Tables

Table 1. OAI Spectrum of interventions 20 Table 2. OAI Paradigms of practice 26 Table 3. Empirically supported OAI outcomes 37 Table 4. Central mechanisms of change within OAI 49 Table 5. Attributes of trauma-responsive organisations 60 Table 6. Attributes of culturally responsive organisations 61 Table 7. Evidence-informed attributes for OAI practice 67 Table 8. Evidence-informed attributes for OAI program design 80 List of Figures

Figure 1. OAI Readiness for change 21 Figure 2. OAI Depth of experience 22 Figure 3. OAI Intensity of experience 23 Figure 4. Typology of Australian OAI 27 Figure 5. Professional OAI flowchart 29 Figure 6. Key mechanisms of change within OAI experiences 52 Figure 7. Key structures and components within OAI 74

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review v vi Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Glossary

The following terms are used within this Review:

Fields of practice • Outdoor Adventure Intervention (OAI) - services that use outdoor adventures as an intentional medium to intervene or influence a given problem or trajectory, including group-based and non-group-based programs. In Australia, OAI sit within the wider field of bush adventure therapy. • Bush Adventure Therapy (BAT) - the suite of Australian interventions that combine nature-contact and uses of adventure with small groups of people towards therapeutic outcomes, including for personal development, learning and therapy aims. BAT encompasses adventure therapy, wilderness therapy and other uses of outdoor or experiential adventure for targeted therapeutic outcomes. A national body of the same name supports the BAT field in Australia. Internationally, BAT services sit within the wider field of international adventure therapy. • International Adventure Therapy (IAT) - the worldwide suite of services that include adventure therapy, wilderness therapy and other uses of outdoor or experiential adventure as interventions or approaches for targeted therapeutic outcomes. The Adventure Therapy International Committee (ATIC) supports the IAT field in over twenty-five countries globally.

Features of Outdoor Adventure Interventions Structures - the basic structure or features of a given OAI, sometimes described as its overarching program model (e.g. preparation, expedition, follow-up). Components - a meaningful set of ‘working parts’ within a given model, sometimes described as key steps in the participant pathway through the OAI (e.g. promotion, recruitment, assessment, orientation, goal-setting, etc.). Processes - this term encompasses the approaches, strategies, activities and practices used by staff (e.g. use of a specific assessment tool, story, game, etc.). Attributes - a quality or inherent feature of safe and effective OAI. Principles - a set of guidelines to assist with the design and implementation of OAI.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review vii Executive Summary

This report provides research evidence and practical guidance for organisations intending to use outdoor adventures as an intervention with young people who have experienced adversities. Berry Street commissioned Adventure Works to undertake this literature review as one component of a yearlong formative evaluation of Berry Street’s Gippsland Wilderness Program (GWP), an expedition-style outdoor adventure intervention for high-risk young people living in Eastern Victoria, Australia. Outdoor adventures are used around the world as a form of intervention, and tend to involve small groups of people in out-of-doors adventures for therapeutic benefits. Within this report, these services are called ‘outdoor adventure interventions’ (OAI). The purpose of this report is to help guide GWP program development, and provide information for other organisations choosing to use outdoor adventures as an intervention with this target group. It offers a synthesis and summary of Australian and international literature on uses of outdoor adventures as an intervention with young people aged 13 to 18 who have experienced adversities, including potential or known trauma. Findings offer a summary of OAI in Australia and internationally; a set of evidence- informed principles to inform future enhancements of the GWP model and practices; and practical advice for practitioners, program managers and organisations. The report also provides an extensive library of literature evidence for further use, in the form of an extended bibliography.

Literature review findings demonstrate that: • Therapeutic OAI are a highly engaging and motivating form of intervention for this age group, and are appropriate for the adolescent stage of development. • Due to their physical, psychological and social dimensions in particular, OAI are well suited to young people who have experienced adversities such as abuse and neglect. • Overall, OAI achieve positive outcomes with this target group, with potential for negative outcomes if OAI are not designed and delivered appropriately. • Boot camps and other forms of OAI that emphasise punitive and coercive approaches are not considered psychologically safe for this target group. • While OAI evaluations have tended to be small, with research methods sometimes lacking rigor, a growing body of empirical evidence exists. • A growing number of OAI are evidence-informed and promising, with potential to become evidence-based. • A significant body of research evidence has been collated and reviewed. Further systematic analysis of the body of research would provide additional guidance for organisations, programs and practitioners seeking to support young people who have experienced adversities.

1 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Findings for young people who have experienced trauma demonstrate that: • Therapeutic OAI typically provide a range of mechanisms though which participants may experience (or re-experience) their own physical-, psychological-, behavioural- and social capabilities and strengths. • OAI mechanisms typically involve opportunities for participants to understand and solve problems, regulate their emotions, build healthy relationships, experience personal competence and have fun. • Evidence supports the use of such OAI processes to help ameliorate harms associated with early life adversities such as childhood abuse or neglect and complex trauma. • Although OAI do not always address participants’ past experiences directly, nor necessarily respond specifically to participants’ trauma histories, they appear generally able to support participants’ physical, psychological, behavioural and social wellbeing. • Safer OAI will assume that participants may carry trauma, and will therefore design trauma-responsive programs and either employ or train trauma- responsive practitioners. • Safer OAI will also be culturally respectful and responsive, in particular in relation to participants of Aboriginal or Torres Strait (or first nation) heritage and participants from culturally and linguistically diverse backgrounds. • Fundamental to participants’ safety and program effectiveness are the values and approach of staff, including their capacity for self-awareness and building of strong relationships, along with their training and skills. • While a strong and growing body of evidence supports the use of OAI with this target group, further work will help to build a clearer and more coherent body of OAI knowledge in support of young people who have experienced adversities.

Findings for program design and monitoring demonstrate that: • Across the breadth of programs supporting at-risk young people, OAI vary widely in context, target group, staffing, program objectives, approaches and outcomes measured. • Given the diverse contexts of OAI, it is broadly recognised that no one model will work for all individuals or groups of at-risk young people. • While some OAI have been replicated, off-the-shelf or manualised OAIs are not necessarily advised. Rather, OAI should be developed for their context, be built on firm evidence, allow flexibility to meet the needs and hopes of participating individuals and the group, and be reviewed appropriately. • Identifying relevant evidence-informed theories of change, and building in evidence-informed practices can assist to minimise risk of harms for participants and staff, and help to maximise likelihood of achieving intended outcomes for OAI participants. • Embedding evaluation processes to monitor program effectiveness will likely support quality and achievement of intended outcomes.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 2 • Despite the complex and challenging needs of young people who have experienced adversities, it appears that a number of OAI services within Australia and internationally are providing engaging, safe and effective experiences.

Attributes of safe and effective outdoor adventure interventions for young people who have experienced adversities include the following: • Across the breadth of effective OAI models supporting young people, common characteristics are present and common ‘rules of thumb’ can be applied to the design and delivery of OAI for young people who have experienced adversities. • Wider literature highlighted the importance of OAI being both trauma-informed and -responsive, and culturally aware and -responsive. • In synthesising findings, it was found that the list of ethical principles developed by the Australian Association for Bush Adventure Therapy (AABAT) offers a useful framework for organising literature review findings. • Findings were developed into a list of ‘OAI attributes’, offering evidence- informed guidance for OAI program design and practice. • The OAI attributes describe programs and practices that are: Positive, Inclusive, Integrative, Collaborative, Voluntary, Readiness-based, Responsive, Holistic, Tailored, Flexible, Cultural, Reflexive and Responsible. • Rather than being prescriptive, the proposed OAI attributes offer guidance for practitioners, programs and organisations to maximise safety and effectiveness. • Actions in these areas will enable OAI to better support the empowerment of young people who have experienced adversities.

3 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 1. Introduction

Background Berry Street commissioned Adventure Works to undertake a formative evaluation of the Gippsland Wilderness Program, an journey-based intervention that has supported at-risk young people in the Gippsland region of Victoria, Australia since the early 1990s. Like other interventions, the Gippsland Wilderness Program (GWP) combines physical activities, outdoor environments and a small group context to help participants make healthy choices and increase their opportunities in life. The central feature of the GWP Boys Program is a challenging eight-day journey through remote mountainous environments. Participants of GWP are nominated and supported by Berry Street’s wider child and family services in the Gippsland region, meaning that young people involved in GWP tend to be at-risk young people who may have experienced adversities such as early life abuse and neglect, and who may, as a result, carry biological, psychological and social impacts of trauma. Because of its use of adventurous journeys as an intervention, GWP sits within the wider field of bush adventure therapy in Australia, and international adventure therapy globally, and within this review is considered an ‘outdoor adventure intervention’ (OAI). This literature review contributes to the formative evaluation of GWP and presents a summary of research to support the development of GWP’s program model and practices. It presents current knowledge on how OAIs are being used with this target group around the world, and offers insights for other organisations seeking to support young people in similar ways. The focus of the review was on interventions for at-risk young people aged 13-18 years who have experienced adversities. ‘Adversities’ may include childhood abuse and neglect, and also the wider range of adversities such as family break down, parental mental illness, poverty, etc. The target group therefore includes at-risk young people who may be under statutory orders, be involved in child protection or out-of-home care settings, and/or are generally ‘at risk’ of a range of difficulties such as mental illness, substance use, offending behaviours and disengagement from educational and vocational activities. The search strategy focused on what would be valuable to GWP and, what would be useful to connected sectors such as the child, youth and family sector and intersecting sectors, such as youth justice, alcohol and other drugs, mental health, education and therapeutic services. The report enables access to the evidence-base regarding uses of OAI with at- risk young people, and may assist OAIs to become evidence-informed and-based. To prepare the reader for the findings of this report, an overview of existing conceptualisations and applications of OAIs is provided.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 4 Guiding questions Broadly, this review examined ‘What works?’ and ‘What do we think might work?’ when using OAIs with this target group. Guiding questions included: 1. How and in what contexts are OAIs being used with this target group? 2. What considerations are important when using OAIs with this target group? 3. What ‘mechanisms of change’ and processes are important, or have been shown to have an impact with this target group? 4. What are the beneficial outcomes of OAIs for this target group? 5. What are some examples of effective OAIs with this target group? 6. What do we know about negative or detrimental outcomes and what doesn’t work? 7. What works for this target group specifically? 8. What implications are there for practitioners and programs providing OAIs with this target group? Primary attention was paid to OAI program descriptions, models and practices used with and on behalf of this target group, and evidence relating to the effects and effectiveness (i.e. outcomes) of those interventions. Research beyond this primary focus was included in the review to help extend the depth and breadth of findings for this target group, including: • Research relating to young people who have experienced serious adversities such as childhood abuse, neglect and family violence; • Other non-OAI therapeutic approaches and comparable treatment effects; • Additional relevant contextual literature to help delineate what it is about OAI that sets it apart from other forms of therapeutic intervention.

Methods used The search methods use in this review were designed to provide an accessible and replicable summary of evidence to identify descriptions of effective OAI programs, models or practices used with ‘at risk’ and vulnerable young people aged 13 to 18, ultimately to inform OAI program design and practice with this target group. On this basis, the review was informed by a systematic review of recent literature, combined with the results of a recent meta-analysis (Bowen, 2016), a previous extensive review of Australia OAI literature (Pryor, 2009) and in light of several other reviews (e.g. Bettman, Tucker, Tracy and Parry, 2014; Skouteris, O’Connor and Cox, 2015). It also includes findings from a significant number of papers sourced from international adventure therapy colleagues, and the technique known as ‘snowball sampling’ through which primary and secondary searches uncover further sources. This review is not a meta-analysis, nor a systematic review of randomised control trial studies; nor is it intended that these results will meet strict Cochrane protocols for the conduct of systematic reviews. While the body of evidence includes results of several relevant meta-analysis and the results of some randomised control trial studies and is therefore strong, it also includes results of single programs with small sample sizes and mixed research methods, adding richness to results.

5 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review

Forms of evidence included in the review include published anecdotal research (primarily program descriptions), theoretical research and empirical research on effective OAI, along with unpublished (grey) literature. For the purpose of the review, ‘effective’ implies both safe delivery and meeting of program aims and objectives. Findings focus on what is deemed effective, based on evidence-informed and evidence-based practices, as well as practice-informed evidence.

Search strategy According to Evans (2001), a systematic review is a summary of all past research on a topic of interest. Evans specifies that unlike the traditional (critical) approach to reviewing literature, systematic reviews utilise the same principles and rigour that is expected of primary research. As the name suggests, ‘systematic reviews are systematic in approach, and use methods that are pre-planned and documented’ (Evans, 2001, p.2) so that upon completion, others can appraise the quality of the review. From this perspective, findings form a clear foundation upon which future literature evidence may be added. The systematic literature review used for this review involved searching electronic databases with an emphasis on literature since 2000 relating to outdoor adventure interventions (OAI) and bush adventure therapy (BAT), which resulted in a search of the entire collections of some 120 publications (from the year 2000). Electronic literature databases included: Ebscohost, Informit, Factiva, PsycINFO and Google Scholar. Investigation of these databases involved using an identical literature search strategy (primary literature search) followed by secondary searches using additional terms. See Appendix 4 for a list of secondary search terms used. Primary literature search strategy:

¡¡ adventure therapy or wilderness therapy or outdoor therapy or bush adventure therapy and

¡¡ outdoor* or nature or wild* and

¡¡ advent* or experi* or camp* or active* or journey or expedition and

¡¡ interven* or therap* or rehab* or program or dev* and

¡¡ at risk or you* or out of home care or out-of-home care or child protection or statutory orders or juvenile or delinquent or drugs or mental or social. Literature evidence base The results of these searches were combined with findings from a previous systematic search undertaken from 2007 to 2009 (Pryor, 2009) and key international and Australian research identified within a review by Bowen and Neil (2012).

7 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Making a call out to international colleagues extended the body of research to include ten more papers from Israel, the USA, the UK, Canada, Hungary and New Zealand. The reason for this wider search was that the international field of OAI is broad and at times loosely connected, and ranges widely across education, health and welfare sectors. Terms and concepts used by OAI programs and between publications vary widely. This diversity provides richness in terms of conceptualisations, approaches and applications, however it makes accessing the full sample of relevant papers highly challenging. Follow-up searches and investigation (snowball sampling) led to gaining an additional 70 papers. So while the systematic literature search using key search terms identified some 120 research papers, correspondence with international colleagues raised a further 80 papers which would otherwise not have been identified, leading to a final review of over 200 papers, many of which are cited and included in the bibliography of this report. All reviewed papers are housed in an electronic library platform. The resultant body of literature became larger than the funding available to complete a systematic analysis of all the papers collected, with more papers collected after the review was finalised. Given the size and significance of this library, further analysis would be warranted.

Terminology and working definitions used in the report Terminology has a role to play in defining who we are talking about, what we are talking about, and what we know works with this target group. The term outdoor adventure intervention (OAI) has been used in recent times to describe a suite of outdoor services that seek developmental, learning or therapeutic outcomes for participants (Pryor, 2008; Williams & Allen, 2012; Bowen et al., 2016). The reason for not including ‘group-based’ in this term originally was that whereas all OAI involve human relationships, not all OAI involve groups. For example, some OAI involve one practitioner with one participant, others involve two practitioners with one participant. While the term ‘group-based’ is relevant for the current Review, it was not a central search term, whereas OAI was. Within Australian literature, the term wilderness therapy has been used more often than adventure therapy (Blake & Katsikas, 2004; Nicholls, 2004), with the term bush adventure therapy (BAT) the primary term used since 2004 to represent the full spectrum of therapeutic outdoor services provided in Australia (Pryor, Carpenter & Townsend, 2005) and since taken up by a national body of the same name, the Australian Association for Bush Adventure Therapy (AABAT, 2017). Additional terms used within Australian literature include: wilderness-adventure; adventure-based wilderness therapy; wilderness-based adventure therapy; outdoor adventure therapy; adventure-based counselling; outdoor experiential programs; therapeutic adventure; psychosocial rehabilitation though adventure; family therapy outdoors; wilderness enhanced programs; bush counselling; socio-environmental therapy; spiritual therapies; rites of passage and wellness rituals. In the USA, the Therapeutic Professional Group of the Association for Experiential Education (AEE, 2017) and the Outdoor Behavioural Healthcare Council (OBHC, 2017)

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 8 support adventure therapy, wilderness therapy and wilderness treatment programs and practices in that context. As a descriptive term, OAI has been found to be useful for programs and services that wish to avoid using the terms ‘therapy’ or ‘therapeutic’- even though OAI sit comfortably within AABAT’s definition for the therapy that occurs within bush adventure therapy. The terms bush adventure therapy (BAT) and international adventure therapy (IAT) are used to describe the full range of programs, practices and services that utilise outdoor environments and experiential or adventure approaches towards intentional therapeutic outcomes in Australia and internationally. More detailed definitions are provided throughout the report. (See the Glossary for working definitions regarding Fields of practice and Features of OAI).

9 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 2. Young people who have experienced adversities

Before moving into the findings of this review, attention is given to the target group that is the focus of this report - young people who have experienced adversities, and consideration of evidence-informed practices to effectively supporting this target group. The ‘target group’ is young people between the ages of 13 and 18 years who have experienced adversities, including childhood maltreatment of abuse and neglect, family violence and other forms of trauma. Such adversities are often associated with experiences in child protection (Child Safety), along with out-of-home care service systems and sometimes homelessness, all of which exacerbate risks for the young people of further trauma. Given their early life experiences, this target group is at increased risk of lifelong trajectories towards mental ill health, substance misuse, antisocial behaviours such as violence and offending, long-term unemployment, and ultimately the perpetuation of intergenerational trauma. Worldwide, OAI have been used to support, challenge and empower young people who have experienced adversities and trauma. Many of these OAI are called ‘youth at risk’ programs, and may or may not address participants’ past adverse experiences directly.

Needs of the target group In April 2016, the Victorian State Government released a major policy initiative, Roadmap for Reform: Strong families, safe children (Department of Health and Human Services, 2016) to improve the lives of vulnerable Victorian children, young people and families. The identified need for this body of work was based on sharp increases in Child Protection reports across the preceding five years (with further increases anticipated); increases in youth crime and recidivism; and significant difficulties transitioning to employment for this target group. The Roadmap and its supporting document, ‘Supporting the Roadmap for Reform: Evidence-informed practice’ (Moore, et al., 2016) broadly outline the backgrounds and needs of this target group as follows: • Family violence, parental mental health and parental substance misuse are common family factors related to child protection reports and interventions, and are commonly associated with child maltreatment of abuse or neglect. Other family factors include poverty, housing and employment issues. • Children exposed to severe adversities such as child maltreatment experiences show great resilience, yet are at greater risk of a range of difficulties (including emotional, behavioural, social and educational) and are more at risk of being perpetrators or victims of violence in the future. • In this way, children and young people who have experienced child maltreatment and inadequate protection and care in their family may enter the statutory Child Protection system and potentially the out-of-home care system, including home-based kith and kin placements, or residential care placements.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 10 • Children and young people enter such placements with complex health, behavioural and developmental needs. Due to lack resources these systems fail to provide adequate support, generally leading to further relationship disruption and abuse experiences, and poorer health and education outcomes than the general population. • Young people leaving care experience high levels of instability and insecurity and are at increased risk of unsafe, unstable and poor quality housing and homelessness, and find it difficult to stay connected to education or employment. The 2014 Victorian Auditor-General’s Report into residential care services for children found that the children have generally been exposed to multiple traumas in the form of family violence, alcohol and drug abuse, and/or sexual, physical and emotional abuse since they were very young, leading to the description of ‘complex trauma’ (cited in CCCH, 2016a, p.14). • Complex trauma results from ‘exposure early in life to multiple, chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature…. often occur(ing) within the child’s caregiving system… (resulting in) profoundly disruptive effects on development, and present(ing) the greatest challenges in working with those affected’. • The severe symptoms and behaviours of children and young people who have experienced complex trauma pose significant challenges for carers and the systems that aim to support and assist them. • The challenge of developing, trialing and implementing evidence-based programs with this target group is significant.

Evidence on effective interventions with this target group The Roadmap lays out an ‘Action Plan’ to increase service capacity in order to better manage complex and severe symptoms and behaviours in children and young people, and ultimately help them overcome the traumatic impacts of abuse and neglect. A key part of the Roadmap’s plan is that all state-funded programs and services be supported by scientific evidence of effectiveness and the use of Co-design. Co- design refers to the process of engaging vulnerable young people and families, professionals delivering services to them, and researchers and experts) in measuring outcomes, building evidence on what works, and improving service responses. ‘Supporting The Roadmap’ offered a menu of evidenced-based practices from prevention and early intervention with vulnerable families through to supporting children in out-of-home-care and supporting young people when they leave care. Despite the report’s intention of preparing and offering a ‘menu’ of evidence-based practices and programs, the report cautions its own use of a ‘program list’ from which practitioners and services can choose. Instead, the report advocates that evidence- informed practice needs to take into account three key sources of evidence: • Evidence-based programs - interventions or programs shown through rigorous formal testing to be effective in building client competences and changing behaviour and functioning.

11 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review • Evidence-based processes - the way in which service providers and the service system as a whole engages and works with individuals and families, individually and collectively. • Client and professional values and beliefs - the crucial role of values and beliefs in determining which goals are important, what interventions and programs are acceptable, and how effective these are. In relation to clients, the importance of understanding their concerns and needs, and the outcomes important to them. According to the report, each of these three areas are important in building evidence- informed practice to achieve positive outcomes for this target group. Given the lack of evidence-based programs and the question of whether an evidence-based program model will work in a different context, the latter two forms of evidence appear to be particularly relevant to delivery of safe and effective OAI with this target group.

Evidence-Based Processes Evidence-based processes are defined as the evidence-based ways that services engage and work with service-users. ‘Supporting The Roadmap’ examined research in five areas: the neurobiology of interpersonal relationships; what helps engage vulnerable families into services; psychotherapy efficacy; effective help-giving practices; and family centered practiced and care. Their seven key findings are summarised below.

1. The importance of the relationship between the practitioner and the service-user: • ‘Relationships should be at the heart of the care system. For those who have suffered traumatic maltreatment at some stage of their lives, sustained supportive relationships represent the most effective form of treatment’ (p.3). • ‘It is the practical transfer of knowledge that creates the conditions for progress, but it is the deeper qualities of the human bond that nourish confidence, inspire self esteem, unlock potential, erode inequality and so have the power to transform’ (Bell & Smerdon, 2011, cited in CCCP, 2016b, p.16).

2. Our capacity to relate to others is supported or undermined by the quality of our own support relationships, pointing to the importance of effective staff supervision and support.

3. Successful engagement of vulnerable and marginalised service-users is enhanced by services that: • Help them feel valued and understood, and that are non-judgmental and honest. • Have respect for their inherent human dignity, and are responsive to their needs, rather than prescriptive. • Allow them to feel in control and help them feel capable, competent and empowered. • Are practical and help them meet their self-defined needs.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 12 • Are timely, providing help when they feel they need it, not weeks, months or even years later. • Provide continuity of care - parents value the sense of security that comes from having a long-term relationship with the same service provider.

4. ‘Psychotherapies work not because of the unique contributions of any particular model of intervention, but because of a set of common factors or mechanisms of change that cut across all effective therapies, known as the common factors approach’ (Sprenkle et al. 2009 cited in CCCH 2016b) namely: • The therapeutic alliance - the joint working relationship between the therapist and the client. • The personal qualities of the therapists themselves.

5. Key features of evidence-based processes repeatedly identified in the research: • Relationship-based • Involve partnerships between professionals and parents • Target goals that parents see as important • Provide parents with choices regarding strategies • Build parental competencies • Are non-stigmatising • Demonstrate cultural awareness and sensitivity, and • Maintain continuity of care.

6. Key qualities needed for relationship-based and partnership-based practice are well understood. Scott et al. (2007) for example nominate four key practitioner qualities considered central to effective working relationships: • Empathy • Respect • Genuineness • Optimism. 7. The importance of providing trauma-informed care for children, young people and adults who live with complex trauma: • Trauma-informed care means ‘knowledge and understanding of how trauma affects people’s lives, their service needs and service usage’ (Evans & Coccoma, 2014, and Wall et al., 2016, cited in CCCHb, 2016). • There is a greater need for:

¡¡ Practitioner and service-user relationships to be long-term in order to build trust and reconfigure patterns.

¡¡ Paying attention to establishing and maintaining boundaries in relationships. • There is further work needed to establish what forms of care are needed by

13 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review different groups, what can be expected of practitioners, and how they can be training in the necessary skills.

Client and professional values and beliefs ‘Supporting the Roadmap’ cited consistent evidence that services are more effective when clients indicate the need for help; when services address the specific issues, needs and outcomes identified by the service-users as important; and when using strategies the clients are happy to use. From this perspective, rather than a use of pre-selected evidence-based programs, research points towards the building of genuine partnerships and the facilitating of collaborative goal-setting opportunities by practitioners (Moore et al., 2012, cited in CCCHb, 2016). The report recommends relational approaches that ‘start with the end in mind’; beginning by collaboratively identifying outcomes sought (goals to be achieved) and working back from there (CCCHb, 2016, p.17).

Evidence-informed practice ‘Supporting the Roadmap’ stated that how services are delivered (i.e. process) is as important as what (i.e. content) is delivered. The report also stated it is quality of the relationship between practitioners and service-users that is central to achieving positive outcomes. From this perspective, the practitioner-client relationship is the key medium through which evidence-based programs should be delivered. In this way, practitioners are not only providers, but also a means or mechanism of treatment, although this is rarely measured (CCCHb, 2016). The report also stated that when working with people facing complex challenges, successful and sustained engagement is necessary but not sufficient for built competencies and positive change. It is the new skills and behaviours that will make a difference to client longer-term outcomes, and these need to be developed from evidence-based program strategies.

Evidence-informed decision-making ‘Supporting the Roadmap’ also recommended using an evidence-informed decision- making framework to guide integration of the various sources of evidence in program development and service delivery. A number of possible frameworks were presented, including one that embeds the decision-making process in a broader human services framework (Moore, 2016, cited in CCCH, 2016).

Trauma-responsive OAI According to Wall, Higgins and Hunter (2016) trauma-informed models of care are based on a set of three theories that provide practical direction for practitioners, programs and host organisations: 1. Attachment theory; 2. Theories on self-regulation and control; and 3. The theory of fundamental attribution error. These authors state that as a minimum, trauma-informed services should aim to do no further harm (through re-traumatisation of individuals) and that a first step in doing no harm is acknowledging that usual operations may inadvertently trigger trauma symptoms.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 14 The peak body for substance abuse and mental health in the USA, called the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014), indicated that trauma-informed care requires four key assumptions on the part of organisations and practitioners: 1) Realisation at all levels of an organisation or system about trauma, and its impacts on individuals, families and communities, 2) Recognition of the signs of trauma, 3) Response - the program, organisation or system responds by applying the principles of a trauma-informed approach, and 4) Resist re-traumatisation - of clients as well as staff. SAMHSA (2014) outlined six key principles of a trauma-responsive approach: 1. Safety - staff and the people they serve feel physically and psychologically safe. 2. Trustworthiness and transparency - organisational operations and decisions are transparent and trust is built. 3. Peer support - peers are involved in supporting service users (peers are individuals with lived experience of trauma or their caregivers, sometimes called trauma survivors). 4. Collaboration and mutuality - the need for a leveling of power differentials between staff and service users, and amongst organisational staff to ensure a collaborative approach to healing. 5. Empowerment, voice and choice - emphasising the need for strengths-based approaches whereby the organisation, and ideally, the whole service delivery system foster recovery and healing. 6. Cultural, historical and gender issues - incorporating processes that move past cultural stereotypes and biases towards embedding of policies, protocols and processes that are responsive to the cultural needs of clients. Mieseler & Myers (2013) stated that to be trauma-sensitive, a practitioner needs to be welcoming, maximise safety, be educated, have resources available, focus on empowerment, use first person language, promote strength through practices, view holistically, share vision across service systems, and address staff issues. To be trauma-responsive, practitioners and service settings need to: recognise and respond to traumatic stress, screen for trauma history, strengthen resilience and protective factors, address the impact on the family, assist children in reducing overwhelming emotion, and help children make new meaning of their lives (Mieseler & Myers, 2013). Drawing on such research sources, it is clear that services supporting young people who have experienced adversities have a responsibility to provide not just a trauma- aware or trauma-informed approach, but a holistic trauma-responsive environment. Given OAI’s multidimensional and holistic service environment, it is widely understood there are many potential triggers and hazards for re-traumatisation. For this reason, it is incumbent upon OAI practitioners, programs and organisations to be trauma-aware and trauma-informed, and arguably, take steps to become trauma- responsive. Becoming trauma-responsive will help to ensure safety (do no harm) and maximise effects (therapeutic outcomes).

15 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Evidence-informed OAI in support of this target group From the review of wider literature, a summary of findings relevant to OAIs for this target group is offered as a starting point: • Give young people a voice so that the OAI experience reflects their needs. • Commence a process of co-design with the young people, service providers and other experts in the area of child development, trauma and treatment early on in the OAI. • Ensure the OAI creates an environment that encourages each young person’s bio-psycho-social development. • Provide opportunities for young people to develop executive functioning and self-regulation skills to help enable positive behaviour and healthy decision- making beyond their OAI experience. • Support young people to maintain or re-engage with education, and support effective transitions from OAI to further training and employment. • Facilitate education and training for OAI staff in trauma-responsive practice - assist staff to better manage symptoms and behaviours in order to contribute to young people’s recovery from the impacts of abuse and neglect. • Facilitate education and training for OAI staff in culturally-responsive practice. • Find effective ways to integrate the OAI experience into the wider and longer- term lives of the young people after their OAI experience.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 16 Outdoor adventure

“programs are gaining worldwide recognition as

an effective approach to engage people struggling with a variety “ of difficult life circumstances in a participatory process of change. 3. Outdoor adventure interventions

Outdoor adventure programs are gaining worldwide recognition as an effective approach to engage people struggling with a variety of difficult life circumstances in a participatory process of change. A combination of access to nature, small groups and adventure activities is found to facilitate powerful experiences of learning and healthy change in a range of service contexts. Internationally, this field connects through the term International Adventure Therapy (IAT) and meets at triennial IAT Conferences facilitated by an international committee currently made up of members from 23 nations (IAT, 2017). In Australia, OAI sit within the wider field of Bush Adventure Therapy (BAT), auspiced by the national body by that name, the Australian Association for Bush Adventure Therapy (AABAT). Australian OAI tailor outdoor adventure experiences towards a range of wellbeing aims for individuals experiencing difficulty, disadvantage or disconnection. In essence, it could be said that OAIs have been in existence within traditional Australian Indigenous communities for millennia; ‘traditional’ Australian OAI combined nature-contact, small groups, and adventure experiences within Indigenous cultural frameworks to promote the socio-ecological wellbeing of whole communities (Pryor, 2009). Contemporary Australian OAI emerged out of this context, and over time has been influenced by local, national and international learning, in particular, professional events such as conferences. The outer perimeters of OAI are wide, yet a set of common elements joins these services into a coherent field of practice. Across all of the different types of OAI that are evident in Australia and beyond, OAI services commonly place an emphasis on: • Time out-of-doors, in contact with nature and natural environments • Experiences of adventure and challenge • Connecting with others, usually in small groups, and • An intentional (though diverse) use of therapeutic relationships and frameworks within the intervention for participants. For Gilbert, Gilsdorf & Ringer (2004), ‘The combination of nature, group and adventure activities provides a rich source of healing potential which in a number of ways goes beyond what therapy has to offer in a more conventional setting’ (p. 31). Through the use of ‘adventure’, participants’ bodies and emotions are engaged in the experience. When conducted in the context of small groups, group activities, and ‘people living together’ these outdoor adventures offer a relatively holistic body-mind-emotional-social experience. In the context of natural landscapes, the environment can become integral to the experience for participants. This combination of aims and methods is considered the basis for a socio-ecological approach to health, where individual, community and environmental health and wellbeing concurrently benefit. While OAI have key elements in common, there are many different models, including many different structures and components.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 18 On the international adventure therapy website (IAT, 2017), a preamble explains that the context in which a program exists has a large influence on the elements incorporated within a particular program, along with intended target group and program aims. For example, a program for disengaged or socially isolated Aboriginal young people in the central desert of Australia will likely have many elements that differ from a program for mental health clients within a medical institution in the USA. The former will likely emphasise cultural elements, unstructured time and use of wide-open natural spaces, while the latter may emphasise clinical therapeutic input, structured interventions, and use of contrived adventure environments. This website categorises practices across a set a set of eight evolving sub-categories: 1) Therapeutic principles, 2) Settings, 3) Social contexts, 4) Adventure activities, 5) Engagement with wider systems, 6) Staffing, 7) Aims and intentions, 8) Target groups. The following section outlines the range of OAI operating in Australia and other dimensions along which different OAI can be located.

Spectrum of interventions Within public health, interventions providing support for whole populations are called ‘upstream’ interventions, and those providing support for people with an identified difficulty, disadvantage or disconnection are called ‘downstream’ interventions (VicHealth, 2005). In Australia, Outdoor Education can be considered an ‘upstream’ strategy, helping to keep people well, whereas Bush Adventure Therapy (BAT) programs tend to work ‘downstream’, to treat, repair or improve the health of individuals either ‘at risk’ or already experiencing a range of difficulties. While BAT programs may work from a strengths-based approach and embed prevention strategies within the experience, it is the participant risks and needs that place these programs ‘downstream’ in the public health arena (Pryor, Carpenter & Townsend, 2005). Australian OAIs have a natural affinity with downstream approaches, but may include or even prioritise preventative or early intervention strategies, depending on the needs of participants and the aims of programs. The following spectrum provides a simple map upon which to place OAI according to the needs of identified individuals, families, communities or subgroups.

19 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Table 1. OAI Spectrum of interventions1

Type of intervention Outdoor Adventure Interventions

Prevention • OAI for the general population. For example, outdoor education, outdoor recreation, adventure pursuits, ¡¡ Universal adventure tourism. ¡¡ Selective • OAI targeted to individuals or a subgroup of the ¡¡ Indicated population requiring intentional support. For example, special year nine programs, or leadership programs.

Early intervention • OAI targeted to higher-risk individuals. For example, programs for those dropping out of mainstream schooling, programs for ‘at risk’ cultural groups. • OAI working with people who display symptoms of ill health, including those who have been diagnosed. For example, Alternative programs for young people who have dropped out of school.

Treatment • OAI working with people who have been diagnosed with a health disorder, to provide early treatment. For example, tailored therapeutic programs for young people with substance abuse disorders. • OAI working to provide standard or adjunct treatment for people suffering from known disorders. For example, therapy programs for young people with depression.

Continuing care • OAI providing longer-term health rehabilitation, (Maintenance) including treatment of existing health disorders. For example, therapeutic community programs for adults with substance use disorders. • OAI providing long-term care, towards a reduction in relapse and recurrence of health disorders. For example, programs for adults self-managing mental health disorders. • OAI providing after-care, including rehabilitation for those with diagnosed disorders who are currently well. For example, community programs and outdoor adventure groups.

1 The Spectrum is adapted from Pryor, Carpenter and Townsend (2005), based on the Spectrum of Interventions for Mental Health Problems and Mental Disorders (CDHAC 2000) originally drawn from The Mental Health Intervention Spectrum (Mrazek & Haggerty 1994).

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 20 Readiness for change Another continuum useful for identifying the function of a particular OAI service is the ‘Stages of Change’ model developed by Prochaske & Di Clemente (1982), and presented here as a ‘Readiness for change’ continuum. ‘Readiness for Change’ recognises that personal changes are progressive and sometimes cyclical, and that the successful establishment of new behaviours may require individuals to cycle through the stages multiple times. Such a continuum reflects the stages individuals may experience in attempting to change behaviours that impact on their health and wellbeing.

Figure 1. OAI Readiness for change

According to this model OAI participants may move from ‘pre-contemplation’, where a concern is first identified or named, through to ‘contemplation’ where a strategy or action is considered, and ‘preparation’ for change where an individual plans to change, to ‘action’ where an individual makes a behavioural change, and is then hopefully ‘maintained’. At any point the individual may revert back to a previous stage of readiness, even to pre-contemplation, any of which may be called relapse. Keleher & Murphy (2004) highlight the assumption that the model assumes individuals are making rational decisions with significant control or agency, which is often not the case with young people, particularly young people who have experienced adversities and who may experience a range of extra barriers in relation to personal behavioural change. It has also been suggested that recognising the external factors that impact on individual choices could strengthen the model. For the purpose of this Review, the model is presented as a way of identifying the various stages participants may be in when they enter into an OAI experience, and the range of behavioural outcomes that may result, including movement from one stage of readiness for change to another.

Depth of intervention Within adventure therapy literature from the USA, Gass (1993) and others have described the level of personal change occurring within a given therapeutic experience as the relative ‘depth’ of the intervention. Based on Australian research, in the Australian context OAIs operate along a wider continuum and in more diverse service contexts than are apparent in the USA. Another key difference between USA models and Australian approaches is the acknowledgement in Australia that all ‘depths’ may potentially result in therapy outcomes; it is the subjective experience of participants that name it therapy or another process. Acknowledgement of the subjectivity of therapy experiences led to use of the term ‘treatment’ in an adapted Australian version of the model (representing medicalised approaches to therapy in the Australian context).

21 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review The following ‘Depth of intervention’ continuum presents a range of Australian approaches and intended outcomes upon which OAI can be placed, in order to highlight whether the service is providing therapy or is therapeutic. The continuum also assists identification of where a given service functions in relation to other services using OAI across different service types. Definitions are provided below.

Figure 2. OAI Depth of experience

• Respite services - take people out of their normal life for time out • Recreation services - emphasise fun engaging activities • Enrichment service - focus on personal development and pro-social experiences • Training services - are an intentional program of skill development tailored to the specific needs of individuals in a group context • Education services - offer a deeper level of intentional learning and includes education for life (in addition to vocation) and personal learning • Treatment services - are clinical services that seek to ameliorate a dysfunction • Palliative care services - aim to maximise the quality of life for people in the position of needing to contemplate life and death.

Intensity of experience The breadth of OAIs spans brief 1-hour interventions, through to extended multi-day interventions and beyond, to achieve intended aims. ‘Intensity of experience’ refers to the frequency, duration and level of commitment required of participants within a given OAI. In this continuum, participant commitment levels span from hour-long ‘Tasters’, through to ‘Ongoing and integrated’ experiences that don’t even have a start or end. Each level of experience may have a central focus on a particular ‘depth of experience’, such as respite, enrichment, treatment or other ‘depth’; the difference lies in the intensity of the experience for participants (Pryor, 2009). Within this breadth, Tasters ready participants for greater involvement, such as longer or more difficult one-off experiences or overnight experiences. When day experiences are placed in order of increasing intensity and challenge, they become sequential and can be used to ready participants for the intensity of extended experiences, even remote and highly committing expedition experiences. Residential experiences are those that involve ‘living in’, where participants live together for an extended period of time. Ongoing/ integrated experiences offer an ultimate level of intensity in that they are seamlessly integrated into the life of a participant’s community, and as such are ‘part of life’. The following ‘Intensity of experience’ continuum presents the range of intensities of OAI used in the Australian context. The continuum identifies different elements that

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 22 may be used within different OAI models, including elements that might be used at different time points within one OAI.

Figure 3. OAI Intensity of experience

Therapeutic intent Several authors have highlighted the importance of differentiating between programs which are therapeutic and those that provide psychotherapy. Berman and Davis- Berman’s (1996) advice for defining if an intervention is therapy is to look at the goals of the program, the process or mechanisms of change employed, and at the therapeutic environment or milieu in programs (pp.2-4). Due to the physical and psychological risks of facilitating OAI, including the possibility of re-traumatisation, practitioners working with young people who have experienced adversities are expected to be alert to their own role and choices in directing experiences for participants, including an awareness of the limits of their own training. As in other sectors, an OAI practitioner providing ‘therapy’ may be considered dangerous if they are attempting to deal with the psychological needs of highly vulnerable clients to a depth beyond their training. For these reasons, OAI practitioners are usually equipped to contain, manage and refer participants on to other supports and services as needed. Therapists of all kinds are expected to understand the theoretical basis of their work, be aware of their own role in the therapy process, establish professional boundaries and emotional safety-nets to ensure safe experiences for participants, and maintain on-going self-reflection through professional supervision sessions (Pryor, Carpenter and Townsend, 2005). For some, alignment with the medical/ psychotherapeutic profession is the best (and only) means of ensuring high quality, safe, ethical practice, and programs or practitioners falling outside of tightly prescribed clinical psychotherapeutic practices should consider using words other than ‘therapy’ (Williams, 2004). Others consider contemporary ecological/postmodern therapy frameworks such as Narrative, Solution-focused, or Systems Therapy approaches to be equally valid and effective, and possibly even more appropriate for use within OAI. At the First South Pacific Wilderness Adventure Therapy Forum held in Bacchus Marsh, Victoria in Australia (Pryor & Carpenter, 2002), although more than half of practitioners were trained in therapy, they more often chose to use alternative terms to describe their work, such as the following: • Interventions - for change • Support - to re-integrate into schools and society • Improving - the participants’ self-management skills • Focusing - on participant successes, finding solutions • Assisting - the process of change and personal growth • Strengthening - connections to others and community (p.38).

23 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review The processes and methods discussed above can be framed as personal growth, educational, therapeutic or a number of other terms according to which lens is used; what assists with determining the frame is the rationale for the intervention, the nature of the intervention, the expertise and approach used by staff, the needs and vulnerabilities of participants, and the point at which an individual chooses to address the need for change in their lives. In a more recent study of 20 Australian OAI, an equal number of practitioners stated they preferred to describe the relational or re-creative effects of OAI experiences as opposed to the therapeutic effects for participants (Pryor, 2009). The Australian Association for Bush Adventure Therapy (AABAT) provides a definition for therapy that has relevance for OAI. According to the website, AABAT understands ‘therapy’ as inclusive of general therapeutic outcomes alongside the specific intent of therapy2. The International Adventure Therapy website defines practice in the following way: IAT is practiced in diverse ways worldwide. Like many therapeutic interventions, adventure therapy participants are generally encouraged to take personal responsibility, work on learning to externalise their internal experiences, and discover new personal possibilities along the way. In general, IAT experiences could be said to include the following therapeutic intentions: • Opportunities for personal growth, change and/or healing • Tailored experiences to meet the needs of individuals and a group • Development of physical, psychological and social safety-nets • Responsible follow-up, transference and integration of the experience (International Adventure Therapy). Wider definitions recognise that the term therapy comes from Greek origins, specifically from Theraps, meaning ‘an attendant’, and referring to the intentional act of ‘attending to’ or ‘paying attention’ to a person (Pryor, 2009). While it is understood that some OAI may choose to maintain distance from the term therapy, it is important to note that OAI participants likely gain therapeutic benefits, and that most OAI sit comfortably within the field of BAT in Australia, and within IAT globally.

Paradigms of practice Across the breadth of Australian OAI, interventions that seek therapeutic outcomes can be viewed according to the relative importance they place on certain characteristics of their intervention experience for participants, reflecting the service’s approach or ‘paradigm’ of practice. These differences have been analysed using a range of dichotomies, including generative through to algorithmic (Loynes, 2007) and positivist through to naturalistic (Pryor, 2007), and in essence compare the relative importance of ‘body’ or ‘soul’ by a given OAI (Russell, 2009). In the latter dichotomy, body reflects the importance of bones and structure and soul reflects the importance of allowing an experience to emerge and evolve with the input of participants, place and time. This section will describe the differences between such paradigms through the terms positivist and naturalistic.

2 Australian Association for Bush Adventure Therapy. (2017). History of the name. Retrieved 10 Oct 2017 from: https:// aabat.org.au/history-of-the-name

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 24 Positivist OAI services follow a scientific, structured, reductionist approach where the experience can be broken down into segments, parts, components and processes. Within this paradigm, the complexities occurring within the OAI experience can be explained and studied as a cause-effect or linear process. Positivist OAI practices are more likely to involve identification of a dysfunction or problem in participating individuals, prescription of a treatment regime or strategy, facilitation of an intervention or series of interventions, and expectation of a predicted outcome based on the original hypothesis or diagnosis. Participants of Positivist OAI experiences have a greater chance of knowing what they can expect prior to participation, and intended outcomes tend to be predetermined by staff and program aims as much as by participants themselves. Naturalistic OAI services are more common in traditional cultural contexts (i.e. within place-based and Indigenous cultures) and within urban settings tend to value social constructivist ideas, intuitive knowing, relationship-focused approaches and community approaches. Within naturalistic OAI, the complexities of the intervention refuse to be broken down or spread along a linear cause-effect pathway. Rather, the experience is co-created, collaborative and emergent according to the rhythms of the group, the setting, the activity and the unfolding experience. Naturalistic OAI approaches sit more comfortably in a postmodern context where subjective interpretation and personal meaning-making are recognised to be at work within the perceptions of both practitioners and participants. Although the experience may involve a set of intentional processes and be surrounded by a comprehensive psycho-social safety-net, participants can expect high levels of choice and decision- making and a co-participatory experience. The following table presents this dichotomy (adapted from Pryor, 2012).

25 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Table 2. OAI Paradigms of practice

Positivist OAI services Naturalistic OAI services

• Practitioners attempt to be objective, • Practitioners acknowledge subjective unbiased and value-free biases and values

• Diagnostic / Prescriptive • Emerging / Evolving (creation of a (predetermined hypothesis verification) working hypothesis)

• Scientific/ Reductionist/ Rationalist • Relational/ Holistic/ Interpretive perspective perspective

• More likely clinical in approach • More likely community-based

• More likely a brief intervention • More likely an integrative intervention

• May involve participants’ significant • May involve participants’ significant others/ families and social systems others/ families and whole communities

• Practitioner-as-expert • Participant-as-expert

• Nature as clinic • Nature as co-therapist

• Adventure outcomes are predicted • Adventure outcomes are unknown

• Outcome-oriented • Process-oriented

• Emphasis on the measurable (verbal, • Emphasis on the subjective physical, cognitive and behavioural) (relational, emotional, social and cultural)

Holistic wellbeing positively impacted upon

Typology of Australian OAI Another way of understanding Australian OAIs is through use of typology described by Pryor (2009), within which programs and services can be compared based on their context, target group, approach and model. The OAI typology is presented within this report to help readers visualise the range, features and mechanisms of change articulated about OAI within the Review. This typology incorporates the key continuum between positivist and naturalistic OAI, but also incorporates other key defining continua. The definitions of each term used in the OAI typology are provided below. Each OAI described or cited within this review may be placed within this Typology.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 26 Figure 4. Typology of Australian OAI

CLINICAL HOLISITIC

BRIEF

Structural Spiral Approach Integrative Approach

SOCIO- ECOLOGICAL

SYSTEMIC WHOLE-OF- COMMUNITY

BODY Paradigm SOUL Paradigm

Brief OAI experiences - have a start and an end, are more easily identified as having a cause and effect pathway, and are more suited to clinical frameworks. Brief OAI experiences take people out of ‘normal life’ for a brief intervention experience. Because they are easier to set aside, break down into their constituent parts and be replicated, brief OAI more easily invite a structural approach to programming, and are more likely to be called a program. Integrative OAI experiences - ebb and flow with peaks and troughs of intensity but are ongoing and happen ‘along the way’. Like brief experiences, integrative OAI may have a start and an end, but they are clearly part of a larger purpose or relationship. They are one option, one event, within a broader process that may have its own start and end. Integrative OAIs may be reduced into constituent parts, but must be viewed within a larger whole. Integrative OAIs more easily invite an emphasis on relationships, which requires fluidity and flexibility in programming, leading this form of OAI to be more likely called a service than a program. Socio-ecological OAI experiences - have no start or end, and are almost seamless or unnoticed in the life of a community; they are ‘part of things’. Like the whole- of-community approach used in one Aboriginal community, socio-ecological OAI practices occur as part of daily life; they are part of the health maintenance of a given community and help to sustain the whole community. These forms of OAI tend to acknowledge of the importance of place, culture, context, story, the subjective, the verbal, the experienced and the shared, leading them to be more likely called ‘community life’ than a service or program.

27 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Structural approaches - refers to the relatively planned, framed and linear forms of OAI that value chronological timelines and distinct compartmentalised program components. Spiral approach - refers to an intentional use of kairos time (‘appropriate time’) which tends to follow the natural ebb and flow of individuals and the group at a given place and time. Positivist OAI services - follow a scientific, structured, reductionist approach where the experience can be broken down into segments, parts, components and processes. Naturalistic BAT services - follow more of a relationship-focused and community approach where the complexities of the intervention refuse to be broken down or spread along a linear cause-effect pathway. Clinical approaches - tend to be include positivist and reductionist approaches within intervention strategies. Holistic approaches - tend include naturalistic, relational approaches within intervention strategies. Systemic approaches - tend to include family/carer/significant other/social networks within intervention strategies. Whole-of-community approaches - tend to include cultural and place-based considerations intervention strategies.

Comprehensive safetynet The following flowchart provides a pictorial overview of organisational actions to support the development of a comprehensive safetynet for program development and delivery. The flowchart allows for diverse OAI programs and practices, and provides a checklist of considerations for increasing professionalism within an organisation or service (Pryor, 2009). The flowchart also illustrates that the more ‘tie-off points’ or ‘anchors used’, the more comprehensive the safetynet will be. The consideration of these elements will help the organisation to hold professional accountability for hosting or delivering OAI.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 28 Figure 5. Professional OAI flowchart

Professional affiliaons

Program logic Program documentaon

Theories & framework Parcipant experiences and Research, feedback Safe Evaluaon & Parcipant Tailored Borrowed & Program Progra Effecve Aims pracces Knowledge Staff Pracce experiences Philosophies & principles and feedback

Staff development Program raonale

Relaonship with Tradional Custodians and Cultural Knowledge Holders

Ethical principles In consultation with the OAI professional community, AABAT developed a list of ethical principles to support safe and effective BAT practice (AABAT, 2017). The principles reflect the values of the broad field and are intended to guide practitioners in how to ensure no harm. They also offer a framework to promote ethical practice across the diverse program settings and professional backgrounds. While practitioners must also rely on their organisational and professional policies and procedures which take account of relevant legislation, government service standards and funding contracts, AABAT encourages organisations to consider how practitioners can engage with each principle in their particular context. In the task of reviewing OAI literature for this report, it was noted that AABAT’s principles are highly consistent with trauma-informed care principles as well as culturally sensitive and -affirmative practices. They were recognised as a useful frame for organising key recommendations for OAI practice and programming, listed below. BAT practitioners work towards: • Positive regard for all people • Respect for differences in culture, gender, age, and identity • Strong family and community connections

29 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review • Transparency, Informed consent, Confidentiality • Voluntary participation (within the confines of service type) • Selection for ‘readiness’ to participate • Attention to individual and group needs and hopes • Supportive physical, psychological, and social environments • Tailored adventure experiences • Provision of options and choices (including supported exits) • Respect for cultural custodianship of country • Increasing self awareness and reflexive practice • Safety and no harm to self, others or natural environments.

International perspectives At a South Pacific gathering of ‘wilderness adventure therapy’ practitioners in 2002, attendees noted that histories, landscapes, and cultural factors had influenced the evolution of programs and services in that region (Carpenter & Pryor, 2002). Internationally, cultural differences play out in areas of participant groups, program intentions, funding sources, programming design and measured outcomes. In a study of wilderness and adventure therapy programs in the UK, USA and New Zealand, Crisp (1997) found that culture, history and tradition have a significant influence on the methods of practice used. Crisp observed differences in how individuals relate to group norms, to the authority of the therapist, to group affiliation, to meaning and connotations of language, and to identity (p.57). While class issues appeared to be significant in how clients are worked with in the UK, things like street gang culture, attitudes to authority and group affiliation tended to shape methods for USA clients (Crisp, 1997, p.64). Differences also play out in the influence of funding and regulation. While perceived risk associated with uses of ‘adventure’ are considered essential ingredients to OAI worldwide, the USA and the UK have higher levels of regulation and control. A key reason for this difference is that in USA and UK contexts a number of deaths have occurred in outdoor programs and wilderness settings, resulting in increased accreditation and licensure processes for staff, programs and organisations as a means of ameliorating public concerns, litigation, and rising insurance (Russell & Harper, 2006). In the USA, the Outdoor Behavioural Healthcare consortium was established in 1996 as a proactive measure to take monitoring, licensure and accreditation into the field’s own hands, “to develop standards of care in outdoor treatment” (Russell 2003, p.356). This consortium has had a significant impact in areas of research, practice, policy and regulation in the USA, and as a result has influenced the nature of research and literature coming out of that nation in that time. As a result, an inordinate emphasis is placed on clinical or medical (i.e. positivistic) models of practice in the USA compared with wider approaches articulated in Australia and other nations (for example, higher prevalence of naturalistic approaches).

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 30 Australian OAI practices are informed by a number of professional affiliations, including education, social work, youth work, allied counselling, psychotherapies and psychology (Dobud 2016). While Australian programs are expected to comply with national outdoor activity standards and professional human service standards, act ethically and meet organisational expectations, and accreditation has commenced in the area of residential camp sites, Australian services are generally freer to assess their own merit and effects than their UK and USA counterparts. While the national body for these practices in Australia (AABAT) has not yet taken up a role of monitoring, licensure or accreditation, most organisations develop their own professional guidelines and risk management approaches within appropriate legal frameworks, largely based on duty of care. These and other cultural features are noteworthy differences in the literature cited in this report.

31 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 4. What the literature says

This section provides a summary of the range of Australian OAI supporting young people; important considerations when working with this target group; a detailed discussion on what is known about key mechanism of change within outdoor adventure interventions; an overview of the range of outcomes sought and achieved for young people through these kinds of interventions, including known and promising outcomes; examples of effective structures, components and practices used within such programs; and recommendations for the design and delivery of safe and effective OAI to empower young people who have experienced adversities.

Current uses of OAI with this target group According to the literature, OAI are used in early intervention and treatment with young people of differing ages and cultures, for ‘therapy’ and development, by qualified and non-qualified clinicians. A summary of the diverse uses of OAI with young people is provided: Early intervention and treatment • OAI are being used effectively with young people across the spectrum of need, including in areas of prevention, early intervention, and treatment, perhaps not continuing care. The majority of OAI support young people in early intervention and treatment. • Across this spectrum, OAI are being used as an engaging and motivating therapeutic context (and as a motivational tool) for positive change at varying points of participants’ lives, and at varying points in their readiness to participate. • It appears that the majority of OAI supporting young people are working in Pre- contemplation or Contemplation stage of change, possibly due to the engaging nature of OAI for this developmental stage, possibly related to participants’ relative immaturity and the earliness of some interventions in young people’s lives. • Ways in which OAI might address participants’ risks and causes of harm were discussed, including whether OAI should attempt to address trauma without the presence or input of a clinician. No mention was made of the need to employ a trauma-specialist therapist within OAI literature. Therapy and development • OAI are being used effectively with young people across a range of service settings, mostly through uses of recreation, enrichment, education and treatment. Treatment includes explicit uses of OAIs to treat or reduce a wellbeing difficulty (including behavioural difficulty), disconnection or disadvantage, sometimes called therapy. • It appears that similar outcomes and effects may be achieved whether or not the term therapy is used, and whether or not young people know they are participating in therapy. Some OAIs avoid use of the term therapy due to stigma associated with this word in some cultural contexts and settings. It is the relationships and processes experienced by the young person that are key.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 32 • More useful than using the term therapy is a delineation as to whether the program is viewed as ‘treatment’ and/or takes on an ‘expert fixing a problem’ approach, or is viewed as a more collaborative and trauma-informed approach to the therapy provided. • As in other sectors, OAI practitioners are expected to practice within the parameters of their training. Whatever the expertise and aims of the intervention, some OAI prefer to use terms such as intervention, personal development or education, or simply refer to the OAI as a program. Staff • Wide-ranging qualifications, expertise and areas of focus were identified in relation to staff. • Many OAI working with young people are explicitly providing therapy, and have trained therapists within the staff team, and many are not. • Several authors discussed staff qualifications and expertise, along with staff gender, numbers and ratios of staff and adults to participants. Participant age and gender • Participant age for a given program, and age mix, was seen as important for individual and group outcomes. Risks of “net widening” and “contamination” were raised in relation to having older and more street-smart participants together with younger more innocent participants, though of course age is not the only moderator of these risks. • The importance of which gender to focus on, whether to include mixed genders, and whether or not to include male leaders in female programs was questioned. Bowen’s meta-analysis noted larger effect sizes for older women, which may dispel a preconception that ‘OAI are for boys’. • Considerations around gender diversity and sexuality identification were not highlighted within OAI literature, but can be assumed to be important given the residual gender stereotypes in relation to outdoor adventuring. • Risks relating to men designing and delivering programs for women, and adults designing programs for young people were raised. The importance of co-production (including co-design) of programs and practices with those representative of the target group were highlighted. Cultural approaches • Culturally aware and culturally sensitive approaches were identified as critical, as well as cultural mix and cultural considerations. • Although all literature reviewed was presented in English, cultural assumptions and philosophical premises of authors were evident. While a diverse range of OAI was represented, authors used their own cultural-based terminologies and applied their own paradigms to descriptions of programs, reporting of outcomes and meaning making from the data presented. • Some OAI supporting Aboriginal or Torres Strait islander people operate from naturalistic approaches, but some don’t. Some expect Aboriginal or Torres Strait

33 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review islander participants to fit in with positivistic or scientific approaches, which adopt a western or European approach that can be unhelpful, alienating, and even oppressive for these target groups. • Risks in delivering programs for Aboriginal and Torres Strait Islander people (First Nations) and people from other culturally and linguistically backgrounds without cultural awareness and cultural-appropriateness were noted. Group selection and mix • Limited attention was paid to the importance of decisions to select individuals or a group, or individuals within a group context, or with the group as a whole. Information on maximum group sizes and usual group sizes, and how to attain the ideal group size was also lacking. • Ways in which programs assess participants’ readiness to participate and select groups of participants were raised as influential on outcomes for participants. • Supporting individuals within a group was also discussed, as was tailoring of program aims to the needs of individuals and the group, or just the group. Delivering the ‘same intervention’ for all individual and groups was raised as a concern. • Few authors raised the importance of identifying difficulties and risks associated with each participant alongside their strengths and protections. • The existence and extent of trauma experiences, including effects on regulation, capacity for personal safety and capacity for social safety (i.e. experiencing challenges in the context of a group) were also relatively lacking. Holistic • Because of the holistic integration of physical, mental, emotional, behavioural, social, cultural, spiritual, and environmental dimensions of OAI, it could be argued that OAIs are amongst the more holistic and multi-dimensional forms of therapeutic intervention for any target group. Mechanisms of change • Key common elements within OAIs that are attributed to achieving healthy change for participants include: time in natural environments; development of a pro-social group culture; uses of challenge and adventure; and therapeutic practices and tools. • The importance of achieving psychological safety for participants was mentioned, including the need to consider the particular needs of individuals within a group; whereas the achievement of physical safety appeared to be a relative given. • Broadly, OAIs are understood to enhance holistic wellbeing for a broad range of target groups and for individuals experiencing multiple difficulties, disadvantages and disconnections, including adversities such as childhood trauma. • Evidence demonstrates potential positive immediate, medium-term and longer- term impacts for individuals across the full spectrum of human wellbeing.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 34 Anecdotal benefits span physical, mental, emotional, behavioural, social, cultural, spiritual, environmental and economic domains of human wellbeing. • Outcomes in areas of mental, emotional, behavioural and social wellbeing are empirically backed, and compare well against other evidence-based and evidence-informed therapeutic modalities across the spectrum of need. Safety • Due to target group and the multi-dimensional nature of OAI, the need to establish a comprehensive risk management framework that supports participants and staff across the breadth risks was discussed. Across this diversity, common themes of maximising safety, seeking effectiveness and helping to empower young people to live healthy lifestyles and be socially connected adults was evident in OAI literature relating to young people who have experienced adversities, including trauma.

Outcomes for young people The body of OAI literature demonstrates that OAIs provide opportunities for young people at lower-risk to higher risk, and young people experiencing a range of presenting difficulties.

Known benefits for young people generally Based on a recent meta-analysis by Bowen and Neill (2013) and subsequent thesis by Bowen (2016), OAIs support short-term outcomes for participants of all ages in areas of emotional, behavioural and social (interpersonal) wellbeing, and these outcomes appear to be maintained in the longer term. An analysis of results for adolescent youth aged 10 to 17 years, demonstrated positive, moderate and significant short-term changes in psychological, behavioural, emotional, and interpersonal domains (.44; CI = .38: .50), which amounts to 67% of participants exceeding the outcomes of an equivalent group who did not participate. The author stated that such magnitude of benefit appears comparable to the majority of efficacious treatments for young people, including individual cognitive behavioural therapy, group cognitive behavioural therapy, play therapy, residential treatment programs, family-based interventions, multi-systemic therapy, outpatient treatment, rational emotive therapy, art therapy, music therapy, acceptance and commitment therapy, restorative justice, solution-focused brief therapy and motivational interviewing. From this perspective, OAIs compare well against a range of other conventional therapies. Authors of the meta-analysis found that average short-term effect size for clinical outcomes such as anxiety, depression and general mental health in young people who engaged in OAIs were not as strong as for some other treatments (e.g. trauma- informed cognitive behaviour therapy, short-term psychodynamic psychotherapy) but was comparable to many other efficacious treatments for adolescent youth participants. In a comparison of younger versus older adolescents (10-14 year olds were compared with 15-17 year olds), effect sizes were found to be generally stronger for the older age group, except in the area of family development. The strongest effects for 15 to

35 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 17 year olds were in areas of academic, behaviour, clinical, physical and self-concept, with the largest differences in physical outcomes across age groups. While the benefits for young people were found to be moderately strong, benefits for older people were found to be stronger; the meta-analysis identified larger effect sizes for older participants generally. A possible reason for this result cited by the authors was that older participants are more likely to voluntarily participate, whereas younger participants are more likely to be forced, coerced or otherwise influenced to participate. In addition, older participants tend to have greater cognitive capacity for decision-making, problem-solving, abstract thinking, reasoning, and self-regulation, which can assist the making and maintaining of helpful changes. It is also possible they have experienced more negative consequences from unhelpful behaviours, and are therefore more motivated to change and are therefore further along in ‘stages of change’. In relation to Australian OAI for young people, authors found lower levels of short-term change (.26; CI = .17: .35) compared with the international aged-based average effect size (.44), and lower levels of change than a number of the most efficacious treatments for youth reported in international literature. These results lead the authors to conclude that Australian OAIs seeking to address psychological, behavioural, emotional, and interpersonal problems in young people could be improved in areas of staff training, program model and therapeutic modality. They recommended that further research be undertaken to identify contributing factors for lower effect sizes in Australian studies. Overall findings from Bowen’s thesis (2016) provide strong support for the use of OAI to achieve academic, behaviour, clinical, family development, self-concept and social development outcomes for Australian adolescents. Both Australian and international studies cited engagement and increased motivation as a key outcome of participation in OAI. A study by Russell (2003) in the USA suggested that ‘Outdoor Behavioural Healthcare’ programs with an appropriate focus on transferring effects to post- treatment and aftercare environments can be effective in the long term for adolescents with emotional and behavioural problems. Russell (2003) found that 97% of all clients who entered treatment completed treatment. This author stated, “Given that most clients who enter treatment are resistant to the process and that coercion into treatment may be a barrier to change, this is an important finding” (p.378). A discrete evaluation by Bowen and Neill (2015) on one Australian OAI program for at risk young people found small to moderate short- and longer-term improvements in life effectiveness (i.e. empowerment), psychological wellbeing, and several aspects of behavioural conduct (e.g. harming, fighting, stealing and vandalism), yet no positive longer-term impacts on psychological distress and some aspects of behaviour. In support of Bowen’s (2016) meta-analysis, the following table summarises evidence- supported benefits for OAI participants spanning physical, mental, emotional, behavioural, social, cultural, spiritual, environmental and economic outcomes based on a systematic review of Australian OAI literature (Pryor, 2009). Not all domains have the same level of supporting evidence; all are included to illustrate the breadth of potential benefits arising from OAIs for people of any age.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 36 Table 3. Empirically supported OAI outcomes

Physical wellbeing • greater physical fitness, competence and confidence • opportunities to reconnect physical and emotional experiences

Mental wellbeing • development of healthier self-concept and self-identity • increases in personal agency and internal locus of control • development of mental confidence and stamina

Emotional wellbeing • increases in self esteem and self worth • higher levels of motivation • reduced depressive symptoms • increased feelings of hope and optimism • reduced feelings of aggression • strengthened feelings of calm and trust

Behavioural wellbeing • more cooperative behaviours • development of life skills and self management skills • reduced antisocial and criminal behaviours, prevention of further crime • improved behaviours at school

Social wellbeing • development of social confidence and social competence • diminished feelings of discrimination and isolation • enhanced feelings of social connection • increased capacity for community participation

Cultural wellbeing • increased understanding and respect for Aboriginal culture and history • connection with Aboriginal country and culture • development of positive sub-cultures in schools, prisons, and accommodations services

Spiritual wellbeing • strengthened harmony and unity within people’s mind, body and soul • development of sense of belonging to place, community and heritage

Economic wellbeing • experiences of successful achievement of personal goals • assisted students to maintain school attendance and complete school • provided a focus and solutions towards education, vocation and employment • assisted participants to develop plans for the future

Environmental • an appreciation of the natural environment wellbeing • strengthened capacity to create a safe and satisfying home environment.

37 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Likely benefits for young people who have experienced adversities While the above section illustrated the breadth of OAI outcomes for young people generally, this section cites outcomes for young people at higher-risk, including those assumed to have experienced severe adversities. It is the broadly stated target group (‘at-risk young people’, ‘young people involved in offending behaviours’ etc.) and the type of intervention (‘treatment’, ‘therapy’, etc.) that places findings within this section rather than the previous section. The amount of research relating directly to OAI outcomes for young people who are noted to have ‘experienced adversities’ is relatively small, and the forms of evidence more limited. One set of research relating to our stated target group found wilderness-based OAI to be effective in improving overall functioning of adolescent clients, as well as specifically reducing symptoms of distress related to interpersonal and mental health challenges. In a meta-analysis of private-pay adolescent wilderness therapy programs Bettman (2012; Bettman et al., 2016) found medium-sized overall effects (effect size, ES = .43), suggesting that wilderness therapy programs for a range of ‘higher-risk’ young people were effective. Earlier meta analyses of wilderness therapy programs reported benefits for participants in areas of personal development such as enhanced self-image, self- concept, internal locus of control, interpersonal skills, and interpersonal development in areas of social competence, interpersonal communication, along with decreases in behavioural problems, antisocial behaviours, delinquent behaviours, and recidivism (Hans 2000; Hattie et al., 1997; Cason & Gillis, 1994; Wilson & Lipsey, 2000). In an Australian study by Gillespie & Allen-Craig (2009) on the effects of a five- week OAI for at risk young men, moderate-to-large positive effect size were found in resilience scores and overall protective factor scores, and these increases were statistically significant. Of the ten protective factors measured, six showed a moderate or larger effect size. Three of these - self-esteem, self-confidence, and community involvement - also showed a significant difference. Two factors, locus- of-control and goal setting, showed a negative effect. The authors wrote, “This study gives strong preliminary support for the use of [OAI] as an intervention to help strengthen protective factors and increase resilience in male adolescents considered at-risk” (p.47). In his study of participants from five ‘Outdoor Behavioural Healthcare’ programs, Russell (2008) found significant reductions in the frequency of substance use by participants post-treatment, with larger post-treatment reductions shown for clients in residential versus community aftercare settings. Russell et al., (2008) measured young people’s motivation to change at the start of the program, and found the majority of people were unmotivated to change. Despite this resistance, participants demonstrated increased readiness to change at the end of the program. In a similar study, Bettmann et al. (2013) found participants who were unmotivated at intake reported equally large increases in functioning post- program compared with those who were more motivated to change at the outset. These findings suggest that resistance to treatment at intake does not reduce the

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 38 effectiveness of the OAI, and that motivation to change may not be a necessary condition for positive therapeutic outcomes. Walsh and Russell (2010) studied the effects of OAI for young people involved in offending behaviours, and found significant improvement in participants’ levels of hope and self-efficacy. However, despite hope being a predictor of reduced recidivism, the study showed no overall difference in recidivism rates between participants and the comparison group. In contrast, Gillis and Gass (2010) and Gillis et al., (2008) found significant decreases in re-arrest rates for young people involved in therapeutic OAI compared with other less-therapeutic forms of OAI over a three- year period. A key difference was that the more effective OAI was integrated within a residential setting where changes could be supported over a longer time period. In an analysis of the effects of OAI for higher-risk young people from the perspective of practitioners, Pryor (2009) reported the following quotes about longevity of changes made: • ‘Their paradigm has fundamentally shifted, (they are) viewing self and the world differently’ • ‘Changes are mostly long-term, it takes a while to process the experience - as they feel more comfortable with it, they try it - we plant seeds’ • ‘A high portion of the young people said the program experience was the most significant event in their life, that they’re now in a different place’. In a study on impacts on family wellbeing, Harper et. al., (2007) found that change in family systems were generally maintained one full year following a three-week wilderness therapy intervention. In a thesis that examined outcomes for young people experiencing mental ill health and drug/alcohol misuse issues, Carpenter (2010) found it is the out-of-doors and the holistic and socio-cultural nature of OAI that differentiates it from conventional counselling and therapy. It is also these elements that make it possible for young people to overcome some of the obstacles associated with their challenging backgrounds. Benefits of OAI for higher-risk young people were cited across the spectrum of wellbeing. Examples are provided below.

Physical wellbeing In a USA study, Tucker, Norton, DeMille & Hobson (2014) found that (OAI) support the development of greater physical competence and confidence, provide a useful setting for the development of healthy eating, good nutrition and body care, assist the development and mastery of certain outdoor skills, and encourage participants to reconnect their physical and emotional experiences. Illustrating the interplay between physical and emotional domains, Australian authors Bowen et al. (2016) found that significant and common outcomes for OAI participants across the breadth of program models include fun, enjoyment, recreation, personal development and social development. These authors suggested that perhaps OAI should have more modest goals regarding addressing problematic behaviours, and more strongly emphasise ‘recreational fun’ as a key intended program outcome.

39 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Mental wellbeing Many reviewed papers identified mental and emotional wellbeing benefits arising from participation in OAI, including the promotion of more optimism about the future. For example, Mutz and Muller (2016) found OAI can foster mental health in youth and young adults, and can also foster at least some of the psychological benefits related to resilience, most notably, self-efficacy and mindfulness. Russell (2003) found that Outdoor Behavioural Healthcare treatment using wilderness therapy approaches “can be effective in reliably and significantly reducing the behavioural and emotional symptoms of adolescents who resemble in-patient populations in terms of presenting pathology” (p.378). In an Australian study on outcomes of an expedition-based OAI, Bowen and Neill (2015) reported that participants looked forward more positively to their futures, felt better about themselves, felt more resilient and courageous, and appeared to genuinely believe that their lives at home and school would be improved through participation in the OAI. By encouraging participants to address issues, the experiences provide a catalyst for attitudinal change. By assisting movement from ‘old me’ to ‘new me’, OAI inspire changes in belief systems (Knowles, 2013). In these ways, OAI support the development of self- concept, providing new personal information that assists participants to develop clearer self-awareness, supports increases in personal agency and internal locus of control, and provide experiences that widen personal choice for participants. Several authors also noted that OAI settings encourage personal reflection and OAI experiences nurture the development of a sense of responsibility. As a result, OAI potentially address the core mental health problems of adolescents at risk of adult mental health problems (including suicide), assist offenders to have greater understanding of their own patterns of offending, and provide an appropriate context for challenging inappropriate cognitions. In addition, OAI experiences assist the development of mental confidence. Bowen and Neill (2015) observed, “Together, the quantitative and qualitative results support the conclusion that this program may offer a viable alternative or adjunct treatment approach to more traditional psychotherapeutic approaches for youth at-risk” (p.51).

Emotional wellbeing A study by Harper & Colley (2007) found improvements in emotional wellbeing and drug and alcohol use for adolescents aged 13-18. These authors reported that findings support the clinical and practical utilisation of adolescent wilderness therapy in the treatment of emotional, behavioural, and substance use problems. In relation to emotional wellbeing outcomes, West & Crompton (2001) found that OAI have the potential to improve resilience and self-concept in at-risk youth. Of the seven OAI these authors reviewed, five resulted in significant improvements in measures of social and emotional wellbeing. Their findings were consistent with previous reviews that found significant positive changes in self-concept in 14 of 16 studies. In relation to emotional benefits, the literature illustrated that OAI have the potential to lift spirits and bring about improvements in mood (e.g. light heartedness,

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 40 happiness, pride, fun, natural highs, hope, satisfaction, optimism, starting to feel healthier) and assist participants to feel more confident. OAI experiences assist to increase participants’ self-esteem, to become more motivated, reduce depressive feelings, lessen feelings of aggression, and lessen feelings of helplessness and hopelessness. Further, OAIs provide a suitable setting for assisting participants to expand their’ ‘feeling’ vocabulary, have the potential to reduce feelings of isolation and promote feelings of acceptance and a sense of belonging, can assist participants to overcome certain fears, may support the development of emotional resiliency, support the development of greater levels of maturity, greater independence, and a greater capacity for responsibility.

Behavioural wellbeing In the above study, West & Crompton (2001) concluded that OAIs may contribute to reducing the negative behaviours typically demonstrated by at-risk youth. In relation to OAIs assisting to change behaviours, Harper et. al. (2007) found positive outcomes in participants’ capacity to address and stabilise problem behaviours across a variety of adolescent and family constructs. Gillis, Gass & Russell (2008) compared behavioural outcomes for participants of three different OAI program models. The first cohort completed a therapeutic outdoor program (therapeutic OAIs), the second completed a residential camping/ school program (school-based OAIs) and the third completed a 90-day specialised treatment program (boot camp OAIs). While all three programs had at times been described as adventure therapy, results clearly indicated that the therapeutic OAI was more effective, with statistically significant lower rates of re-arrest one-, two- and three years following release. In results of a review of Australian OAIs, Bowen et al. (2016) stated, “OAIs appear to be well positioned to make a unique and valuable contribution to the development of young people, addressing their behaviour problems and potentially supporting prevention and treatment of mental health problems” (p.26). In relation to behavioural benefits, literature illustrated that OAIs have the potential to provide a catalyst for behaviour change. For example, in relation to offending behaviours, OAIs can lessen antisocial and criminal behaviours, assist to prevent crime, and assist a reduction in recidivism/ re-offending. Generally, OAIs appear to both prompt and encourage personal responsibility for behaviours, such taking up proactive behaviours regarding healthy nutrition. OAIs may also help young people to develop independence in relation to personal illness, such as their taking of medication, and motivation to reduce alcohol/drug dependency and misuse issues. Numerous studies illustrate that through direct feedback and natural consequences, OAIs can serve to challenge inappropriate or irresponsible behaviours, provide an arena for trying out new roles, assist students to improve behaviours at school, equipping participants with new skills for home use, and assisting young people to improve behaviours at home. By providing tangible experiences of task completion, OAIs improve young peoples’ ability and confidence to complete future tasks, and provide an appropriate context for trailing new ways of acting and behaving.

41 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Social wellbeing Social wellbeing was one of the most cited outcomes of OAI literature reviewed, and even cited as a catalyst for pro-social change in ‘at risk’ youth. Social outcomes cited numerous times include the development of trust, increased understanding about others, and enhanced communication skills, social skills and friendship skills, leading to greater social ability and social competence (i.e. ‘more socialised’). Through development of a ‘sense of belonging’, OAI experiences can help to diminish feelings of discrimination and isolation for at-risk young people (Carpenter, 2008). OAIs were cited as supporting the development of relationships between participants and leaders, also between students and teachers, chaplains and schools, police and young people, mentor and mentored relationships, as well as peer relationships between people with both similar and different backgrounds. Family relationships were also cited as benefitting from OAI. In a study by Bettman and Tucker (2011), improved social and family wellbeing were found in participants who had participated in a wilderness therapy intervention. Specific social outcomes included improved attachment to parents and decreased anger and emotional disconnection towards parents. For these authors, findings may have been indicative of the program instilling particular coping-strategies and affecting decision-making processes in participants. Another USA study found that integrating the OAI within a longer-term residential program increased the likelihood that participants could translate their newly developed social skills to other settings (Norton, Wisner, Krugh & Penn 2014). Few studies cited that OAI participants were able to translate their newly developed social skills to the broader community, thereby assisting to increase participants’ community connectedness; this may be an area for further work.

Cultural wellbeing Numerous Australia studies highlighted the benefits of OAIs in building understanding and respect for Aboriginal culture and history, and the use of OAIs to effectively respond to the experiences and needs of Indigenous Australian young people as well as adults (for example, Rae & Nichols, 2012). In relation to cultural wellbeing, OAI have also been found to improve school culture, improve prison culture, and assist to improve relationships between Aboriginal and non-Aboriginal people. According to numerous studies, OAI can improve relations between police and young people, including Aboriginal young people and police and ‘ethnic youth’ with police through development of dispute resolution strategies - but OAI do not always achieve this outcome. An Australian OAI that led to improved relationships between police and young people highlighted it was the positive personalities of individual police involved that allowed this to happen rather than the model itself (Pryor, Pryor & Bowen, 2016). With adequate consideration of cultural implications and imperatives, OAIs can also offer a Rite of passage or Initiation into adulthood (e.g. Norris, 2011).

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 42 Economic wellbeing Closely connected with improvements in social and cultural domains, some OAI studies cited outcomes in the area of economic wellbeing, whereby participants had initiated or consolidated a stronger pathway towards education, training or employment. According to numerous studies, OAI can assist students to complete school, provide a focus for employment and solutions for employment difficulties, offer an alternative to mainstream education, and can provide an alternative education setting. OAI can also provide a context and focus for training. In a study by Bowen & Neill (2015) a 13-year-old female commented, “My future [looks] good . . . because I’ve set myself up. Like, might try harder in school, and I’ve decided where I want to be, where I want to go, and what I have to do to get there” (p.48). This OAI participant appeared clearer about her future vocational choices and her potential future role in the economic life of her community. The results of an evaluation undertaken by Crisp (2003) of an OAI that had supported over 1000 young men generally assessed as having ‘poor social competence and school adjustment’, and who had ‘clinical levels of delinquent behaviours and poor coping strategies’ showed the program to be effective and functioning at a very high standard of service delivery. Following the program, participants reported significant reductions in delinquent behaviours and significant improvements in self- esteem and style of coping. These changes appeared to be consistent and robust. Two years after the program over 75% of the participants were still engaged in education, training or employment. A similar percentage reported the maintenance of better relationships with family and others. Many graduates enjoyed an ongoing involvement with the rural program base, where they regularly returned for themed residential experiences and acted as mentors for newer participants. Numerous studies highlighted the benefits of OAI as an effective setting for the development of life skills, work skills (e.g. commitment to work, cooperation, planning), personal development and growth.

Environmental wellbeing Based on the potential and understood benefits of human-nature connections and time spent in nature, both in terms of benefits for humans and benefits for the natural environment, some OAI programs record outcomes in relation to environmental wellbeing, which has spin off benefits for both humans and nature. An illustration of this is a participant quote cited by Bowen and Neill (2016) in which a participant reflects on the benefits they have gained from time in nature: “Since we’ve been out here... I’ve been able to think, and just breathe. And just, yeah have all this open space (p.47). Cole, Erdman and Rothblum (1994) reported that a side benefit to wilderness therapy is perhaps its most significant contribution: ‘it is not possible to spend any length of time in nature without developing a sense of wonderment and awe about its magnificence. It is a small step, then, from connection with the non-human natural world to urgency about environmentalism. Ultimately what nurtures and heals the individual also nurtures and heals the planet” (p.4).

43 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review OAI can nurture an appreciation of the natural environment, can help to develop a sense of responsibility and reciprocity in taking care of the natural environment, can illustrate human dependence on nature, and the consequences of human mistreatment of nature (e.g. Norton 2012).

Likely longitudinal benefits for young people who have experienced adversities In examining OAI outcomes for participants over time, Fernee et al., (2016) cited a USA longitudinal study that found two years after an OAI, participants were just realizing the impact of their OAI experience. After hating the OAI at the time, one client expressed that two years on, it was one of the most important experiences of his life. This finding suggests that in some cases, improvements can be maintained or even increased over time - even when individuals originally found the experience difficult or loathsome. In order to support the maintenance of changes made, Norton (2010) listed four components that should be included in a community-based program for youth who have completed wilderness programs: ongoing outdoor programming, community service placements, alternative education programs, and counselling. Based on Australian literature evidence and the direct experiences of over 40 OAI practitioners, Pryor (2009) summarised the likely benefits of OAI over time. Here they have been compiled to illustrate likely longitudinal benefits for young people who have experienced adversities.

Immediate wellbeing benefits Either straight away or within days of their OAI experience, participants typically gain a range of wellbeing benefits. From physical activity and eating healthy nutritious food, OAI participants experience immediate physical fitness and strength benefits, and increases in energy and vitality. Their mental health benefits from gaining more knowledge and understanding about self, more motivation to plan ahead, and a greater sense of calm, clarity and ability to concentrate. Emotionally, participants experience a more positive mood and increased self- confidence, resulting in more optimism and motivation. Direct experiences of completing daily living tasks, taking responsibility for self and others, and showing initiative, along with the removal of drugs and alcohol and lack of opportunity to undertake antisocial actions means participants’ behaviours benefit. Socially and culturally, participants benefit from new friendships and social contacts, new positive peer groups, healthy lifestyle choices and for some, stronger connections with their culture and heritage through time spent on country. Spiritually, participants benefit from increased sense of belonging within the group and through connections with nature, natural environments and special places, and they may gain greater interest in existential matters. Experiences of contact with nature provide immediate benefits such as lowering of blood pressure and increasing sense of calm, along with greater understanding about the importance of humans’ relationships with nature and an ethic of care for

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 44 natural environments. Through direct experiences of caring for others and nature, participants are more likely to feel and show care for significant others and home environments. Through OAI, participants are connected with wider social and support networks and increased knowledge about study, employment and bush skills, which increases their motivation to participate economically in their community through further training or employment.

Short-term wellbeing benefits Within weeks after their intervention experience, some participants are able to maintain changes made, and some wellbeing benefits may have even increased. For some OAI participants, physical fitness and strength are maintained through continued physical activity and healthy eating, and are actively choosing to go on outdoor adventures such as camping for leisure. Having learnt to be more comfortable with self, participants continue to feel calmer, more confident, comfortable and relaxed. Some participants continue to self reflect and are able to maintain a sense of focus, clarity and groundedness. As participants test out new behaviours and relationships, their sense of identity continues to shift, relationships change, and ideas for a positive future emerge. Having learnt to plan ahead, some continue regular physical activity, make healthy lifestyle choices, and set goals for the future. Emotionally, some participants continue to feel happier, even high, and positive moods are more easily attained. Positive feelings tend to be accompanied by higher levels of optimism and motivation. Participants are more communicative and socially engaged, more motivated to participate in school and community activities, and tend to be able to manage themselves and take personal responsibility for their actions, resulting in healthier behaviours. Some continue to treat people with more respect and receive respect in return. Socially and culturally, participants continue to feel more confident and cooperative, and continue to be open to making new friends and consolidate old relationships in new ways. They tend to remain willing to participate in groups, and even take up leadership opportunities. Some are consolidate shifts they’ve made in their peer group, and choose to spend time with different people. Some feel a change in role and status and are forging new networks. Some have a deepened sense of responsibility for their culture and/ or traditions. Spiritually, participants tend to maintain a stronger sense of personal values such as what is right and wrong, and more often reflect on their own role in situations and circumstances. Sense of belonging continues, and participants are actively able to nurture sense of belonging in various ways. Memories of nature and special places are still relatively fresh and positive, and participants continue to talk about their experiences. Some are more confidently engaging in home, family and community environments, and some are playing a more active role in creating a positive home environment. In the medium term, participants continue to feel positive about their choices for positive participation in the economic life of their community, are more financially organised, have more information about education, training or employment options, and have started to craft a future role for self in the wider community.

45 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Longer-term wellbeing benefits Wellbeing benefits gained from an OAI may be maintained for months or even years after the OAI experience. After their OAI experience, some participants are able to maintain regular physical activity, good sleeping patterns and healthy eating habits. Their capacity to care for self in areas such as meal preparation, maintaining hygiene, managing personal medication and planning healthy leisure activities may be consolidating into a generally healthy lifestyle. In such cases participants’ physical self-confidence and competence will continue to grow, and they will continue to be willing to try new physical challenges and adventures. Their relationships with health services, including mental health services may be lessened, or be approached with more personal agency and confidence. Mentally, participants will feel stronger and will have developed more coping strategies, as well as more strategies to feel calm, clear and focused. Some continue to view the future with optimism, hope and purpose. Emotionally, participants still draw strength and happiness from their OAI experience and find they’re able to create new positive memories. Self-acceptance, confidence and identity consolidate, and participants find they can deal with new crisis in healthy ways. Participants’ behaviours demonstrate they are learning more about self care, self control, making safer choices, managing their personal responses, and taking responsibility for self and others. Life skills are growing, healthy lifestyle choices are being made, including personal choices to undertake physical activity and spend time in nature. Participants’ social confidence and competence continues to grow, they are able to maintain friendships, and continue to be open to meeting new people and making new friends. Family and intimate relationships are benefiting from increasing self- awareness and more measured behaviours. Participants are finding they’re more able to create healthy relationships and avoid unhealthy ones, including unhealthy peer groups. Some participants continue to develop understandings about their cultural heritage and traditional connections with natural environments, and experience an increasing sense of responsibility for maintaining their family connections and Indigenous culture. Participants will be maturing physically and emotionally, and as a result will feel more able to see broader perspectives and more confident in facing difficult situations. Spiritually, participants continue to develop sense of self in relation to others, including sense of belonging. If they experienced a sense of fresh start or re-birth during the OAI, they will continue to develop and consolidate their sense of personal purpose and identity and may connect, reconnect or cease ties with religious or spiritual traditions. Some participants will draw on their memories of the outdoors, and actively strengthen their relationship with a special place, or broader connections with natural environments. Some will make conscious choices about the home environments they wish to create, and work at making a safe satisfying home environment. Increasing knowledge about lifestyle options combined with increasing personal agency may see some participants choosing to undertake education, training or employment that matches with their newfound self knowledge or passions. After three months, participants will generally be more connected with the economic life of their community, including wider services or social structures.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 46 In comparing OAI with other forms of intervention, OAI were favoured compared with: conventional health services, hospitals, mental health services, psychiatric disability services, psycho-social disability rehabilitation support services (PDRSS), rehabilitation services, other support services, alcohol and other drug (AOD) services, youth services, counselling services, family counselling services and Youth Justice services. In relation to methodologies used, experienced practitioners reported they had heard favourable comparisons compared with use of ‘day centres’, alternative schools, school guidance counselling, youth justice interventions, youth work, accommodation services and psychiatric care (Pryor, 2009). In relation to cost effectiveness and value for money, experienced OAI practitioners have heard both favourable and unfavourable comparisons about the cost of their OAI, with some viewed OAI as cheap and others viewed OAI as expensive. When compared with the costs of residential programs, youth detention, medical treatment or hospitalisation, OAI are widely considered a viable and highly cost-effective treatment (Pryor, 2009). Blake and Katsikas (2004) remind us that for those who have experienced trauma, the resolution of trauma may never be final, that recovery may never be complete; that the impact of a traumatic event or series of traumatic events may continue to reverberate throughout the survivor’s lifecycle and into the next generation.

Mechanisms of change Early (pre-2000) descriptions of the change processes at work within OAI suggested it is the unfamiliar physical environment, the group social context and the challenging problem-solving tasks that lead participants to consider changing their lives; other cited variables included the individual characteristics of the instructors and participants (Carpenter, 2008). Defining what are the important active design features of OAI programs has been a focus of OAI researchers for at least two decades; prior to that, at least Australian research focused more on describing programs (Pryor, 2009). For some researchers ‘active design features’ are a question of what participants think are the most important parts of their program experience; for others it is a question of program logic, measured outcomes and causal effects. Others use the term ‘theory of change’ to describe a proposed mechanism of change. Previously cited USA research identified key OAI mechanisms of: a) the wilderness, b) the physical self, and c) the social self (Russell & Farnum 2004). Later research by a Norwegian team adapted these dimensions to include: c) the psychosocial self (in place of the social self), acknowledging the interconnectedness of all factors and the existence of emergent processes and outcomes (Fernee et al. 2016). Such theorising is supportive of OAI comprising a socio-ecological intervention, with benefits for participants crossing bio-psycho-socio-eco domains of wellbeing. A USA study on adolescents experiencing levels of depression that impacted on their functioning found that key OAI mechanisms included time in nature, the group environment, physical challenge, experiences of contemplation, and positive communication with their parents (Norton, 2010).

47 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review From observations of a New Zealand-based OAI, the complex and layered contextual factors at work within OAIs were described as involving individuals (including clients and practitioners), interpersonal relationships (i.e. the group), the intervention setting (including the environmental, cultural and social conditions), and the infrastructure, which includes the wider social, economic, and cultural context of the program (Jansen & Pawson 2012). Pryor’s (2009) Australian study of twenty Australian OAI that included interviews with over 40 practitioners found the essential common mechanisms of change to include: a) contact with nature experiences, b) group experiences, c) adventure experiences, d) therapy and counselling experiences, and e) skill development experiences. Combined with findings from a concurrent systematic literature review, the skill development experience later came to form part of the ‘experiential adventure’ subgroup of mechanisms. Deane and Harré (2014) analysed both the program descriptions and outcomes of OAIs from a broad range of literature to determine the ultimate ‘youth adventure program’. Their model incorporated key stages of the experiential learning cycle, having instructors with multi faceted skills, and having a socially diverse group. For these authors, the four critical components of OAI experiences for this target group included the importance of: a novel physical environment, challenging yet attainable activities with authentic and clear consequences, an intense and supportive small- group social setting and a psychological change process. In their meta-analysis Bowen and Neill (2013) noted key elements that differentiate adventure therapy from other psychotherapeutic treatment modalities include an emphasis on: learning through experience (active and direct use of client participation and responsibility), the presence of and interactions with nature, use of perceived risk to heighten arousal and to create eustress (positive response to stress), meaningful engagement in adventure experiences, solution-based focus on positive change (present and future functional behaviour), an ethic of care and support, a holistic process and effect on participants, and a group-based intervention such that psychosocial and group processes are often integral to the experience and treatment methodology (p.28). In his thesis examining of international adventure therapy outcomes, Bowen (2016) identified key mechanisms as involving: a) small groups, b) nature-contact, c) adventure activities, and d) therapeutic processes. Carpenter (2008) described OAI as dynamic transitional or changing spaces, highlighting that what will largely determine the outcomes for a set of individuals within a group includes: complex interactions over time within each unique group, their internal relationships, and the particular challenges they face. This review was organised across four mechanisms of change: a) nature, b) group, c) adventure, and d) therapeutic frame. These four key mechanisms are associated with positive outcomes, and yet we have much to learn on why or how they work. These mechanisms remain theoretical and are evidenced by association rather than by identified causal links. While not necessarily entirely explanatory, most of the philosophies, theories, structures, components and practices evident within OAI research can be accommodated within one of these four areas.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 48 Table 4. Central mechanisms of change within OAIs

Mechanism Defining Central Clarifying statements of change terms evidence base

1. Nature Time spent in Benefits of Includes the philosophies, nature / natural passive and theories, values and environments active nature practices applied to the contact experience by staff in the service of intended outcomes.

2. Group Experiences Benefits of social Includes the philosophies, of being a connection and theories, values and member of a support practices applied to the small supportive experience by staff in group the service of intended outcomes.

3. Adventure Active Benefits of Includes the philosophies, participation experiential theories, values and in adventures adventure practices applied to the involving experience by staff in physical activity the service of intended and challenge outcomes.

4. Therapeutic Intentional use Benefits of Includes the values, frame of therapeutic therapeutic philosophies, theories, structures, processes, structures, components components counselling and and practices applied to and practices the therapeutic the experience by staff in by staff and the relationship the service of intended organisation (alliance) outcomes.

Based on literature evidence, explanatory hypothesis are offered in relation to each key mechanism of change, as follows: 1. Nature • Time in natural environments engages people in the natural rhythms of day and night, weather, and changing seasons, helping to attune them with the natural cycles of life. • Living out of doors compels people to notice and respond to changing weather conditions and other environmental variables, and to experience the consequences of their own behaviours and responses in relation to those variables. • Physical journeying through nature requires participants to notice water sources, places of protection, comfort and beauty, and cope with changing terrain. • As people move through nature they can develop a sense of identity,

49 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review relationship or kinship with features in the landscape such as birds, animals, mountains or rivers. • Without the distractions of urbanisation and mechanisation, longer time in natural environments enhances participants’ sense of relationship or belonging to nature. • Time away from home and sense of remoteness allows people to reflect and see their normal life differently. • For young people who have experienced adversities, contact with nature offers a restorative medium for personal change. 2. Group • A safe group environment and social support helps participants to develop social and emotional skills, to understand, respect, relate and respond to others in new pro-social (positive) ways. • Opportunities for the development of shared group identity, sense of belonging and bonding develop participants’ social confidence and social competence. • Facilitated social experiences that include role modeling by positive adults assist young people towards constructive transitions to adulthood. • Opportunities to feel safe and respected within a group can be transferred to respecting others and being respected in wider social settings, such as family and the wider community. • For young people who have experienced adversities, supportive social connections within small groups offer a reclaiming medium for personal change. 3. Adventure • Outdoor activities engage participants in physical activity and a sense of adventure. • Sense of adventure engages participants in a heightened level of useful positive stress (eustress) in the context of safety (rather than risk-taking to harm self or others). • A state of eustress facilitates new coping strategies and recreational interests to emerge, allowing for change and growth and wellbeing. • Self-propelled journeys develop participants’ physical and mental strength, self- reliance, resilience and sense of mastery. • Challenge and commitment compel persistence, completion and sense of achievement. • Opportunities to weigh benefits and risks and make decisions with consequences develop participants’ judgment and decision-making capacities. • For young people who have experienced adversities, experiential adventures offer a transformative medium for personal change. 4. Therapeutic frame • An identified rationale and theoretical approach guides staff intentions and increases the quality and consistency of services delivered.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 50 • Awareness and consideration of participant histories helps prevent trauma and re-traumatisation. • A comprehensive holistic safetynet ensures potential physical, psychological and socio-cultural harms are minimised and managed. • A qualified and coherent staff team with diverse backgrounds and skills and clearly identified roles based on personal strengths creates a supportive social milieu. • Staff modeling respect for gender and cultural diversity helps participants feel respected and affirmed and practice respect and acceptance of others. • Staff modeling healthy habits, lifestyles, behaviours and relationships present a constructive contrast for participants who have not experienced such examples. • A shared leadership approach that is strength-based and respectful builds a strong therapeutic alliance between staff and participants. • By providing support balanced with sometimes challenging participants’ beliefs, attitudes, and behaviours staff can develop a robust and trusted relationship with participants through which participants’ can test and adapt their own beliefs, attitudes and behaviours. • By providing sequential and concrete experiences for participants that build on each experience and build participants’ confidence, staff can facilitate greater handing over of responsibility and skill development to participants and enable the development of empowerment and leadership. • Time and space for participants to reflect on their experiences, gain insights, decide on future courses of action and try out new personal approaches/ behaviours (sometimes called experiential learning) allows participants to learn by doing, and practice new preferred actions and responses. • Time and space for participants to be alone with themselves, either physically alone or alone in a group space, helps build self awareness, comfortability with self, personal coping strategies, self soothing strategies, and self confidence. • For young people who have experienced trauma, a safe social context provided by leaders enables a reduction in hyper-vigilance to keep safe, and enables increased leanings. • Facilitated group processes help develop participants’ individual and shared stories and positive group identity. • Facilitated individual processes help develop participants’ self-reflection, self- awareness and personal responsibility. • Facilitated group and individual conversations about pathways to manhood and womanhood assist young participants towards healthy transitions to adulthood. • The provision of end of journey support, after program care, referral pathways to other services and links to community opportunities increases the longevity of effective experiences.

51 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review • For young people who have experienced adversities, the importance of safe and effective program design and therapeutic alliance between staff and participants can turn a simple outdoor adventure into an empowering medium for personal change. The following figure illustrates the importance of these four key mechanisms of change within OAI. Within the figure below, they are ordered according to their emphasis on biological wellbeing, psychological wellbeing, social wellbeing and ecological wellbeing.

Figure 6. Key mechanisms of change within OAI experiences

Contact Social Therapeutic Experiential with nature relationships frame adventure

Examples of effective OAI

1. Catalyst program Bowen & Neill (2015) evaluated the outcomes for 53 at-risk young people arising from participation in an OAI operating in Australia called the PCYC Bornhoffen Catalyst program. The program model involved 15 program days over 10-12 weeks made up of a three-day camp, a nine-day journey and three single follow-up days. Prior to the program almost all the young people reported experiencing one or more risk factors, most commonly family problems, social problems with peers, behavioural conduct problems at school, and psychological issues including depression and suicidality. From interviews with participants, a clear outcome of the program was that participants had taken steps towards their overcoming their challenging backgrounds. In addition to this outcome, five other major themes emerged: 1) contending with adversity, 2) personal development, 3) social development, 4) motivation to work for change, and 5) optimistic future outlook. Results indicated small to moderate short- and longer-term improvements in life effectiveness, psychological wellbeing, and several aspects of behavioural conduct. There were no positive longer-term impacts on psychological distress and some aspects of behaviour. Together, quantitative and qualitative results supported the conclusion that the Catalyst program may offer a viable alternative or adjunct treatment approach to more traditional psychotherapeutic approaches for youth at-risk. Conclusions indicated that OAI’s such as the Catalyst program can have a meaningful impact on life effectiveness, mental health, and behavioural functioning, with potential to help change the course of young people at risk of adverse outcomes in their educational, vocational, and life-course pathways.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 52 2. Wilderness Adventure Therapy Bowen, Neill & Crisp (20153) evaluated an OAI model operating in Australia called WAT. The program involved a 10-week part-time intervention delivered by three practitioners. The model includes intake processes, seven one-day activities, a two- day overnight training camp and a five-day expedition, along with up to eight weekly active group therapy sessions. Termination processes include a review of goals and unresolved needs/issues, identification of post-treatment goals, and the enlisting of psycho-social supports and follow-up. Participating young people were out-patients of a regional state-based adolescent mental health service, and showed risk factors such as school failure, poor body image and eating problems, substance abuse, being victims of sexual abuse or assault, and/or family dysfunction. The most common reason for referral was conduct/ behaviour (29%) followed by depression (21%), anxiety (14%), identity/self esteem (14%), relationship problems (14%) and psychosis (8%). Results indicated that the overall short-term effect size for WAT participants was small, positive and statistically significant (0.26), representing a 15% overall improvement consistent with 60% of participants reporting improvements at the end of the program. For participants who reported clinical levels of depressive symptoms pre-program, the short-term effect size was large, positive, and statistically significant (0.80), and was retained in the longer-term. This is consistent with 79% of clinical range participants (with depression) reporting improvements in depressive symptoms at the end of the program and at follow-up. The pre-program mean for these participants pre-program was in the severe range. This moved to the mild range by the end of the program, and remained in the mild range at the three-month follow-up. It seems that clients with depressive disorders, or at least depressive symptoms, responded well, with clinically meaningful reductions in symptoms. Such magnitude of benefit appears comparable with the most efficacious treatments reported in the literature. The authors reported that, overall, the findings provide promising evidence that WAT interventions can offer a viable alternative treatment modality to more traditional psychotherapeutic approaches for youth at-risk.

3. Xena Program Pryor, Townsend, Maller and Field (20064) evaluated an OAI in Australia delivered by The Outdoor Experience called the Women’s Xena Program. The program was a six- week treatment intervention for young women aged 14 to 24 who had experienced drug and alcohol issues, mental ill health and associated trauma. The model was developed and delivered by three female practitioners and involved preliminary recruitment and selection processes, two weeks of therapeutic group work leading towards a 12-day bush journey, followed by two weeks of intensive follow-up group work, and one-to-one aftercare support towards vocational pathways or other support services. (This model was delivered annually from 2000 to 2006). Prior to the program, almost all the young women had experienced trauma in early life (including physical and sexual abuse), histories of suicide ideation and episodes of self-harm, a mental health diagnosis, alcohol- and other drug-related issues, physical ailments, estrangement from families, growing up in care, living in supported

3 Bowen, D. J., Neill, J. T. & Crisp, S. J. R. (2016). Wilderness adventure therapy effects on the mental health of youth participants. Evaluation and Program Planning, 58(2016) 49-59. 4 Pryor, A., Townsend, M., Maller, C., & Field, K. (2006). Health and well-being naturally: “Contact with nature” in health promotion for targeted individuals, communities and populations. Health Promotion Journal of Australia, 17(2) 114–123.

53 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review accommodation, fear of meeting new people, lack of trust/ sense of safety, difficulty with interpersonal relationships, early school-leaving and long-term unemployment. Based on qualitative data that included observations, interviews with participants and interviews with referrers, results indicated that two of five participants identified improvements in living circumstances and family relationships, all five identified improvements in the self-management of physical ill health issues, all five identified improvements in drug/alcohol use, all five identified improvements in their capacity to self-manage symptoms of mental ill health and mental disorders, all five identified improvements in their capacity to socially connect, and three of five participants identified the desire to move towards greater economic participation in the community. Authors concluded that the program had provided a safe and effective intervention that had positively impacted all five women who had completed the program, across the breadth of human health and wellbeing.

4. Bridging the Gap Pryor, Pryor and Bowen (2016) evaluated a pilot OAI in Australia called Bridging the Gap, financed by Victoria Police and delivered by Eastern Access Community Health in partnership with the Youth Support and Advocacy Service. The program was delivered over a ten-week period and involved delivery of twelve modules, plus parent sessions at key points during and at completion of the program. The twelve modules spanned ten single activity days, a five-day river journey and two-day celebration camp. Based on initial assessment, young people had generally experienced early substance use, family conflict and violence or other trauma experiences, educational/ learning difficulties, disengagement from school, conduct issues, early involvement with police, involvement with antisocial peers, early mental health symptoms, lack of healthy recreational activities, limited positive adult role models (males in particular) and limited wider social supports. Quantitative results indicated improvements for participants across all measures and sources at the end of the program and three months later in areas of: • substance use • general health, wellbeing and safety (alcohol and other drug use, wellbeing, safety, achieving potential, family/other people) • mental health • behaviour misconduct (cheating, drug use, wagging, fighting, vehicles, stealing, harming, and vandalising) • life effectiveness (emotional resilience, goal setting, healthy risk-taking, locus of control, self-awareness, self-esteem, self-confidence, communication skills, community engagement and cooperative teamwork) • physical wellbeing • school engagement • family relationships • future outlook

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 54 • personal outcomes (i.e. value of the program for personal growth and development, including self-confidence, self-awareness, self-esteem, goal setting, healthy risk-taking, locus of control, and emotional control) • social outcomes (i.e. value of the program for developing social skills and relationships, communication skills, cooperative teamwork, and community engagement). Exceptions to these positive changes included deterioration at the end of the program in some participants’ general health, wellbeing and safety measure (according to parents and school staff), mental health (according to parents) and behaviour misconduct (by school staff.) However, each of these areas showed improvement again at the follow-up time-point three months after the intervention. Qualitative results likewise indicated significant benefits and outcomes for the participants at the end of the program and three months later. Of particular interest is that prior to the program, participants reported low concern for ‘how they were getting on’, whereas at the end of the program they reported a significant increase in motivation to make positive changes as a result of the program, suggesting the program helped raise participants’ awareness about the issues they faced, and helped to shift them from ‘pre-contemplation’ to ‘contemplation’ or even to ‘action’ in relation to making positive changes. Positive outcomes were reported for individual participants, their families and their communities. Overall, BtG achieved its intended aim to provide early intervention for at-risk young people aged 13-16 years, including intervening in substance use and associated harms such as offending behaviours. Benchmarked against other similar programs for this age group internationally, BtG showed stronger than expected outcomes. Participants’ self-reported short-term effect sizes were higher than Bowen and Neill’s (2013) aged-based short-term benchmarks for 10-17 year olds compared with other similar adventure-based interventions internationally (p.162).

Ineffective and negative outcomes None of the reviewed literature stated that OAI solve all problems or are a panacea. In an early description of OAI with young people who had experienced involvement with the youth justice system, O’Brien, Harrison and Heath (1995) reported that programs don’t change lives, but they are a powerful tool in the context of a wider program and gradually produce change. In their review of research relating to outcomes for young people engaged in wilderness therapy for mental health treatment, Fernee et al. (2016) noted that overall, there were very few accounts incidences or examples of wilderness therapy not working, either partially or entirely. These authors noted this may be due to convenience sampling, where clients are willing to participate in research because of their positive experience. For them, the majority of studies appeared selective in terms of reporting positive experiences, thereby displaying a reluctance to explore neutral or negative results in more detail. Several papers noted the reality that due to early childhood trauma and ensuing life circumstances, some young people will not be ready or willing to participate in group programs, and some will not be ready or willing to participate in extended journeys.

55 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Pointon (2012) noted the importance of highlighting the important differences between therapeutic OAI and coercive boot camps by clearly articulating and promoting the theoretical differences. She noted the lack of outcome evidence relating to boot camp efficacy and stated, “Throughout all aspects of the adventure therapy industry it is important ensure Australian programs are adhering to safety guidelines/ standards set by world leading programs” (p.35). The review found some discussion of the limitations of OAI, some examples of negative outcomes, some cautionary notes regarding specific program components, and some special considerations that needed to be taken into account with this target group for outcomes to be positive. Russell (2005) cautioned against the notion that wilderness therapy can ‘fix’ young people or ameliorate all forms of previous and future suffering. Of two participants who found an OAI ineffective, one said they were too young and scared by the experience at the time (aged 14) and the other said they preferred to deal with the personal issues in the environment where they were happening rather than in the middle of nowhere. In a study on wilderness therapy participants Davis-Berman and Berman (2012) stated that while positive outcomes were reported, none of their respondents described their experience as life changing or life altering: “Rather than providing an inoculation from future difficulties, the experience empowered participants to bear and cope with the hardships” (p.336). Fischer and Attah (2001) reported problems associated with non-voluntary participation, and also when OAI were not culturally aligned to the participating young people. Their case example described a mismatch in having white middle class adults facilitate OAI experiences for African American participants of lower socio-economic status. Not all empirical studies were supportive of all aspects of OAI practice. Some studies highlighted the reality that OAI are not necessarily consistent and are not necessarily delivered without fault, error, or misunderstanding, and some noted negative outcomes for participants. Pryor (2009) reported a study of 20 Australian OAI in which practitioners were asked, ‘From your observations, how often do negative outcomes occur for participants as a direct result of the program?’ Practitioners from four of the 20 programs responded ‘sometimes; 12 programs responded ‘rarely’; and 4 programs responded ‘never’. The previously described Bridging the Gap program was funded to intervene early in relation to young peoples’ drug and alcohol use and offending behaviours, was part time in nature, and involved police officers in the delivery of the program. The evaluation identified risks associated with bringing groups of at-risk young people together, and found the following neutral, mixed or detrimental outcomes: • No change - One parent observed no change in their child’s attitude to police due to a negative personal experience of a police officer involved in the program. Another participant reported they used cannabis regularly prior to the program (verified by their parent) and reported they had made no changes to their use by the end of the program or their (also verified by their parent).

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 56 • Mixed results - According to school staff, three participants showed no change in school attendance and behaviours, and one displayed deterioration in behaviours. Another area of qualitative results that showed mixed results were behaviour outcomes in relation to drug and alcohol use. Pre-program one young person had reported using a number of illicit substances whereas at post- program he had ceased use of those but had increased alcohol use, a result that was maintained at follow-up three months after the program. Two other participants also reported their alcohol use had increased during the program. • Negative results - According to staff and participants, there had been some bragging about drug use and risk-taking by one participant early on in the program that had needed to be managed by facilitators to promote a positive group culture. This was largely achieved, however it appeared that several participants may have met together socially and used substances together outside of the program. Facilitators noted the need to place greater emphasis on setting suitable boundaries regarding substance use at the outset and ongoing throughout the program to prevent unhelpful peer influences (Pryor, Pryor & Bowen 2016). In a direct response to criticisms about efficacy with young offenders, Gillis, Gass & Russell (2008) investigated outcomes of OAI to identify which models worked. From their analysis of archival program data for 15,311 young males aged 8 to 18 years old who were previously engaged in antisocial and criminal behaviours and who had participated in OAI of various kinds, they found the trajectories of those who participated in therapeutic OAI resulted in significantly lower rates of re-arrest at one, two and three years after release compared with other forms of outdoor programing, such as residential programs and boot camps. Fernee et al. (2016) cautioned that due to high numbers of wilderness therapy participants reporting problems with previous conventional treatments, it can be expected that the vast majority will not comply nor benefit from wilderness therapy treatment. In Pryor’s (2009) study of 20 Australian OAI programs, practitioners reported how often participants ‘opt out’ of the program before completion. Practitioners from eight of 20 programs stated ‘sometimes; eight of 20 programs stated ‘rarely’; and four of 20 programs stated ‘never’. In relation to programs for boys at risk of violence, Rhule (2005) warned about the impact of group dynamics on already vulnerable young people where the presence of many aggressive peers together in a group has been shown to contribute to a shifting of social norms, including a higher level of social acceptability and reinforcement for aggression. In a similar way, taking a problem-group out of school can promote group bonding, which may have both positive and negative impacts and can increase estrangement from school. Rhule concludes that we should: enlist parent/teacher monitoring; monitor outcomes over a long period of time; make more use of qualitative feedback to flag issues that may be outside of the facilitator’s field of vision; and have a more open discussion about the risks of doing more harm than good, generally in the academic/ practitioner community and with individual young people, their families and referrers.

57 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Several researchers and authors called for caution when using OAI with vulnerable young people. For example, Berman and Berman (2013) state that OAI need to conform to the standards of other ancillary healthcare providers. Their belief is that if adventure therapy programs are going to make inroads into the field of mental health, they need to be able to relate to a mental health model for a continuum of care. Several USA authors state that while experiences in nature can certainly be therapeutic, direct care must be provided by a professional for the experience to be considered therapy (for example, Gass et. al. 2012; Bettman et. al., 2016). In addition to cautionary notes, the current review identified a number of special considerations that may need to be taken into account with this target group for outcomes to be positive. In an early example, Palmer (1995) undertook a comparative analysis of OAI and found that programs based on problematic assumptions about young people’s behaviour could do more harm than good, for example those programs designed to meet the objective of social control rather than social justice. The same finding could be extrapolated for programs using coercive or manipulative methods to change participants’ behaviours, as occurs within non-voluntary boot camp-style OAI. Brown (2002) observed OAI group sessions and used participant-generated data to examine the power relations and roles within group conversations. Findings demonstrated that the staff leader or facilitator was positioned as gatekeeper, through which participant contributions must be mediated. This finding appeared to confound a key aim of seeking to instill confidence and empower decision-making by the participants themselves. Not all OAI literature evidence is positive, and not all research is conducted in a faultless manner. Such examples highlight potential areas for future program development and research.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 58

... findings indicate there

“are some key identifiable practices, structures, components and processes “ that actively contribute to benefits for young people. 5. What works

While the volume of literature reviewed is wide and relatively deep, few OAI models working with young people who have experienced trauma have been evaluated in relation to their effects on trauma symptomology - and if they have been evaluated, they have not necessarily provided a rich description of OAI processes or change mechanisms. While several papers explain the process or the outcomes, few do both in a way that contextualises findings for this purpose, and few compare OAI models, meaning that the review of literature often involved comparing ‘apples with oranges’. Nevertheless, findings indicate there are some key identifiable practices, structures, components and processes that actively contribute to benefits for young people.

Responding to history and heritage The USA peak body for substance abuse and mental health services (SAMHSA 2016) stated, “A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognises the signs and symptoms of trauma in clients, families, staff and others involved in the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resits re- traumatization” (p.9). SAMHSA cited a set of considerations seen as foundational for the provision of safe and effective intervention environments for young people who have experienced adversities such as trauma. Based on research, SAMHSA recommends providing a trauma-responsive organisational environment by supporting efforts in the direction of: Safety, Trustworthiness, Peer involvement, Collaboration and Empowerment while paying attention to Culture, history and gender, as follows:

Table 5. Attributes of trauma-responsive organisations

Safety Staff and the people they serve feel physically and psychologically safe.

Trustworthiness Organisational operations and decisions are transparent and trust is and transparency built.

Peer support ‘Peer’ is the terminology SAMHSA use for individuals with lived experience of trauma or their caregivers. Peers are also known as “trauma survivors”.

Collaboration and This principle is about leveling power differentials between staff and mutuality clients and amongst organisational staff to ensure a collaborative approach to healing.

Empowerment, This principle emphasises the strengths-based nature of trauma- voice and choice informed care. The organisation-and ideally the whole service delivery system-fosters recovery and healing.

Cultural, historical A trauma-informed approach incorporates processes that move past and gender issues cultural stereotypes and biases, and incorporates policies, protocols and processes that are responsive to the cultural needs of clients.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 60 ‘What works’ for young people who have experienced adversities is the provision of a trauma-responsive OAI environment.

Likewise, for Aboriginal and Torres Strait Islander young people, research and literature supports the strengthening of cultural connections based on respect for Indigenous place-based knowledge and special relationships with places. Furthermore, a professional safetynet based on collegiality; built-in feedback mechanisms from critical friends will assist to guide the direction and motives of the organisation. To invest in the efficacy of OAI, organisations are encouraged to pay attention to program effectiveness, program longevity and ongoing program refinement. The current review highlighted the importance of providing a cultural-responsive organisational environment by supporting efforts in the direction of: Respect, Collegiality and Appropriate evidence building.

Table 6. Attributes of culturally responsive organisations

Respect a. Acknowledging local place-based history b. Valuing knowledge of traditional cultural custodians c. Building and maintaining relationships with traditional custodians and cultural knowledge holders d. Providing culturally appropriate supervision and professional development for staff e. Being accountable to a nominated external Indigenous community.

Collegiality a. Maintain affiliations with relevant professional bodies, stay up to date with current practice, research and dilemmas b. Clearly articulate organisational philosophies and principles, theories and frameworks, research and evaluation and borrowed knowledges c. Support development of program rationale and program logic d. Back up program intentions with policies and procedures and staff development e. Support development of program and participants aims f. Establish ongoing feedback loops for receiving participant experiences and stories g. Establish ongoing feedback loops for receiving staff experienced and stories h. Support tailored program practices and flexibility in program delivery.

Appropriate a. Embed action-oriented culturally appropriate evaluation, with staff evidence involvement and participant consultation building b. Build understanding of cost effectiveness and social returns, including the downstream costs of not delivering the OAI c. Consider expansion and replication in culturally appropriate ways and places d. Support the OAI towards becoming evidence-based, and contribute to the growing body of knowledge on the effects and effectiveness of using OAI.

61 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review ‘What works’ for young people of Aboriginal and Torres Strait Islander heritage is the provision of a culturally responsive OAI environment.

Staff values, skills, approaches and self awareness OAI vary in intensity, frequency, length, depth and emphasis. Each OAI service has a unique structure, and features span from brief and rigid three-phased linear services, to multi-dimensional, circular, integrative services able to be flexibly tailored for the specific needs of individuals. Australian OAI tend to use simple adventure modalities such as bushwalking (rather than highly structured group programs, or multi-activity days, for example). Many Australian OAI use journey experiences of 6-12 days duration, longer journeys are used in the USA. OAI in Australia at least tend to emphasise participant-as-expert approaches and socio-community approaches rather than behavioural approaches where participants are considered to require guidance, control and/or behaviour modification. Given all these differences and similarities, the question of what makes some OAI safer, more effective or more empowering for young people who have experienced adversity, including trauma, is a complex one. Research suggests that like participants, OAI staff will benefit from a trauma- responsive and culturally responsive environment. Ringer (2016) believes the most valuable tool an OAI practitioner has is his or herself. Given the importance of therapeutic alliance on intervention effects, staff values, skills, approach and self-awareness can be seen as the primary therapeutic tool. A number of studies mentioned the importance of staff and staff practices in relation to the safety and effectiveness of OAI, including: • staff values • staff training and skills • staff approach • staff self-awareness (including self-knowledge)

Staff values Norton et al. (2014) stated that strengths-based values can lead to a safer, more accepting space in which young people can take off their facades and develop their authentic selves. For Gillis and Gass (2003), OAI are effective because of the following values and attributes, which can be woven into the practices of safe, effective and empowering OAI practitioners: • Use of adventure - turns passive therapeutic analysis and interaction into active and multidimensional experiences, which help to provide insight into participants’ personal actions, language, thoughts and belief systems, and feelings and perceptions, thus, therapeutic interaction becomes holistic.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 62 • Use of unfamiliar experiences - provides a medium that is ‘contrasting’ to a participants’ current reality state. Contrast is used to help participants see elements of their lives that tend to be overlooked and to gain new perspectives. • Use of eustress, or the healthy use of stress - provides manageable challenges. To maintain equilibrium in challenging situations, it is necessary for participants to change their behaviours and use positive problem-solving abilities. The adaptive processes are typically healthy and a means for them to achieve therapeutic objectives. • Use of resolvable conflict - provides opportunities for growth through dilemmas that are organised (e.g., to meet the needs of the group), incremental (e.g., in terms of complexity and consequence), concrete (e.g., tasks are easily recognisable and typically possess a definite beginning and end), manageable (e.g., can be accomplished by groups with the resources they possess), consequential (e.g., the results, positive or negative, generally have an immediate, non-arbitrary, and direct effect on clients), and holistic (e.g., address a variety of learning domains, including cognitive, social, emotional, and psychomotor learning). • Use of a focus on abilities - provides participants with opportunities to focus on their abilities rather than on their dysfunctions. As a result, rather than being resistant in therapy, participants are challenged to stretch perceived limitations and discover untapped resources and strengths, and are directed toward achieving self-empowerment by establishing and maintaining functional change. • Use of active practitioner - provide a change in the role of therapist from passive and stationary to more active (e.g., designing and framing adventure experiences around critical issues for participants and focusing on the development of specific treatment outcomes). As the ‘experience’ takes on the central medium for orchestrating change, the therapist/practitioner is able to take on a more ‘mobile’ role (e.g., supporting, joining, confronting) in the co-construction of change processes with the group. As a result, many of the barriers limiting interaction between therapist/ practitioner and participants are removed. Thus, therapists/ practitioners often become more approachable and achieve greater interaction with group members when compared to traditional group therapists. Baim and Guthrie (2012) provided a list of guiding beliefs for the delivery of interventions (non-OAI) for boys at risk of family violence. Their list included: a strengths-based approach; treat the whole child (not just the problem); involve the family/carers; emphasise wellness rather than illness/deficit; it must be relationship- based working (as opposed to ‘fixing the young person’ by applying a set of techniques); focus on healing and resilience (rather than pathology); recognise that children and young people are continually developing physically, socially, morally, emotionally, neurologically and intellectually; recognise the great hope within early intervention, that young people have the potential to ‘move on’ from patterns of behaviour (pp.50-51).

63 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Staff training and skills Pointon (2012) examined three features of effective OAI with young people involved in offending behaviours and stated, “As relationships are the key change agent of majority of intervention programs it is therefore important to select, train and retain good quality staff.” (p.32). Although acknowledged that one of the most important ways to ensure ethical and effective practice within OAI is through training and development for all program staff, varying views were expressed in the literature about whether causes of harm (i.e. trauma) must be addressed directly, and whether or not trained therapists or trauma- specialist clinicians are required to support OAI working with this target group. Some programs demonstrated positive developmental impacts and wellbeing effects without directly addressing trauma experiences and without having trauma-specialist therapists as on-ground staff members. Tucker & Norton (2013) reported that in a random sample of 646 clinical social workers in the USA who were members of the National Association of Social Workers who were surveyed, more than one third (35.1%) reported using adventure-based activities for therapeutic purposes in their social work practice. However, only 40 individuals (17.6%) out of the 227 respondents who utilised these techniques had formal training. Of those, only 20 specifically reported having received specific training on the therapeutic application of adventure activities. Although this study did not look at the formal impact this lack of training had on clients, the authors stated professionals agree that there is greater potential for negative psychological effects, as well as harmful physical effects on clients. For Marchand & Russell (2013), the importance of staff training in OAI is highlighted due to the intensity of the experience and risk of burnout for professionals.

Staff approach Schell, Cotton & Luxmore (2012) stated that the combined effect of: a) adhering to the intervention philosophy, b) carefully structuring and grading activities, c) ongoing group support, and d) keeping the personal goals of the client in mind, leads to an improvement in self-esteem, mastery and performance of personal goals and a positive and successful experience. In Pryor’s (2009) investigation of the foundations, features and wellbeing impacts of 20 Australian OAI, experienced OAI practitioners stated that the most important considerations were that the intervention be: tailored to individuals; that participants be considered co-players and co-designers –being ‘done with’ rather than being ‘done to’; and that key phases for change are provided, i.e. that transitions are supported. In the same study, an Australian OAI practitioner stated that staff approach was vital to the attainment of outcomes for participants: “To be able to do the work, staff need to be able to develop relationships with the community, be perceived as useful (i.e. do what you say you’ll do), be a problem-solver (i.e. assist where the needs are, and don’t be constricted within your role), be flexible, have personal immunity to violence (i.e. good clinical supervision), have exceptional networking skills (i.e. people, relationships, relationships with services), and a vision for each individual that includes hope” (Pryor 2009).

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 64 Based on an evaluation of a bush adventure therapy program for young women who had experienced severe adversities that included abuse and neglect, it was argued that OAI offer an effective catalyst for change based on the following approaches: • Engagement - OAI provide an attractive option, allowing the easy creation of rapport • Assessment - OAI provide more information about complex difficulties, leading to greater understanding • Therapeutic alliance - OAI support the development of constructive relationships that are based on genuine, authentic care • Healthy attachment - OAI assist development of healthy attachments with self, others, adventure and nature • Natural consequences - OAI provide an experience of direct and immediate information, free of judgment, providing natural motivation for participation, problem-solving, and taking on responsibility • Experiential learning - OAI involve a whole body process that necessitates action-reflection, a process that supports the integration and reinforcement of lessons learned • A whole experience - OAI provide a physical, sensory, psychological, behavioural, social, spiritual and environmental experience • Space and time set aside - OAI allow the opportunity for reflection, and to see things from a different perspectives, encouraging new possibilities to emerge in settings free from distractions and intrusions • A safe environment - OAI provide a setting that is raw, challenging, real and lived, but also supportive, trustworthy, and honest, and • Mystery - OAI offer surprises, the unknown, and the unexpected (Pryor et al., 2006). In an evaluation of a youth-at-risk OAI, amongst other findings, Chenery (2003) found it was the spontaneous actions and responses of practitioners, including their capacity for fun, joy, and ‘being in the moment’ created a place and time for teachable moments and learning within an OAI.

Staff self-awareness Pointen (2012) noted the importance of structured supervision sessions, “Just as staff from other psychological and health fields have structured supervision, facilitators/ therapists in (OAI) need to have regular structured supervision. This is seen as best practice in other therapy programs and helps prevent burnout, provides a safe place to debrief and provides different perspectives” (p.32). For this author, supervision helps offer a solution-focused way of encouraging practitioners to identify their own solutions to problems, and gain greater personal insight. Results of the evaluation of the Catalyst program by Bowen and Neill (2015) identified six major themes identified by participants as being salient features of their experience: a) overcoming challenging backgrounds (e.g., family problems, social problems with peers, behavioural conduct, problems at school, and psychological

65 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review issues); b) contending with adversity (e.g., physical, mental, emotional and social challenges which caused distress, conflict and crisis during the program); c) personal development (e.g., positive thinking, self-belief, courage, self-control, managing emotions, persistence in overcoming problems); d) social development (e.g., developing trust and respect for others, communication and cooperative teamwork skills); e) motivation to work for change (e.g. realising that an intentional effort was required to improve health and well-being); and f) a more optimistic outlook on the future (e.g., looking more positively toward the future, greater belief that lives at home and school would be improved). These findings illustrate the importance of staff ‘holding understanding of participants’ needs’ ‘ as their priority (rather than being distracted by their own needs). Such a list offers a possible focus for staff attention before, during and after the program, as well as an order of priority for staff training and development. In Pryor’s (2009) study of 20 Australian OAI services, practitioners 17 of 20 services believed staff skills and experience were essential for ensuring participant safety. Ten of 20 further believed that staff skill and staff capacity to ‘let go and hand over to participants to some degree’ was as essential for participant psychological safety and program effectiveness, requiring high levels of self-awareness.

Attributes of safe and effective OAI practitioners The literature review identified numerous ways in which OAI can maximise safety and effectiveness through staff values, training, skills, approaches and levels of personal self-awareness. For example: • The more a staff team understands different beliefs, attitudes and behaviours, and the more they understand different cultures and languages, gender and sexual identifications the more effective they will be at relating with participants from all walks of life. • The more adults (and good adult mentor role models) involved in a given OAI experience, the more examples of adulthood a young person can choose to emulate and be like, and the more options for healthy adult support they will have after the OAI experience has ended. • The more encouraging staff can be, the more a young person will feel liked and supported. • The more a practitioner understands about his or her self, the more effective they will be in supporting others.

‘What works’ is staff having well-matched values and approaches, adequate training and skills, and high levels of self-awareness.

The following table provides guidance for OAI practitioners. The information is gleaned from research- and practice-based evidence, and organised according to AABAT’s ethical guidelines. Examples of practitioner strategies are offered for each attribute.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 66 Table 7. Evidence-informed attributes for OAI practice

Examples of OAI OAI Practice Principle practitioner questions relating to each attribute

Positive Recognising participants’ • You’ve been referred to this expertise in finding solutions program because someone to their own dilemmas helps thought you could do it. Would support participant-driven you like to do it? change, and mobilises • Wow, you did that well. If you participants’ capacity to did that, what else can you do? determine their own preferred • Knowing that you can do futures. things, what else might you want to do?

Inclusive Holding a sense of curious • What is important to you? fascination towards participants • What is the same and different with different values, lifestyles about how we see that? and relational patterns • What else can you tell me shows respect for diverse about the way you see that? backgrounds and identities.

Integrative Involving significant others • Who do you see as part of your and wider community members family, and what are the good at strategic points can help to things about your relationship strengthen participants’ social with them? supports and extend program • Who do you feel connected benefits. with, and what is good about that connection or relationship?

Collaborative Relating with participants as • This is the group you will be partners, practitioners can going away with, and this is maintain confidentiality while the kind of thing we’ll be doing also working towards genuine together. Have a think about informed consent, shared if you want to do more of that decision-making and co- with this group. created solutions. • We write notes on participants and the program so that we remember what we did and what people got from the program. Would you like to see what we’ve written about you?

Voluntary Enabling group experiences to • A few people think you can be influenced by the needs and do this program, including us. hopes of participating Would you like to give it a go?

67 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review individuals enables genuine • Some people might say you voluntary participation. Where couldn’t do this, but we think participation is mandatory, such you can. What do you think? as in medical or justice settings, • Some people don’t want to do practitioners may work to a program like this because motivate participants to opt in it’s too hard. What do you for their own reasons. think about doing hard things?

Readiness- Working in partnership with • If you were ready to do this based potential participants and thing, what would that look significant others to decide like for you? on suitability and timing of • How would you know you participation (and to what were ready to do this thing? level) supports successful • How can we help you feel engagement and commitment. ready to do this thing?

Responsive Understanding participants’ • What do you hope to stories enables effective experience or gain from this consideration of individual program? and group needs. Safe OAI • If after this program everything are trauma-informed and was good for you, what responsive to participants’ would that look like, and what individual histories. will have happened on this program?’ • How does this group need to be, and how do we need to relate to each other, so that everyone can get the most from the experience?’

Holistic Establishing a holistic safetynet • What will you need to feel includes consideration of safe (think physically, mentally, biological, psychological, emotionally, behaviourally, sociocultural and environmental socially, culturally, spiritually, risks and benefits. Participants environmentally and are more likely to challenge economically)? themselves to grow and learn • How will we all keep each in healthy ways if they are other safe, what will we do/ grounded in feelings of safety not do? and security.

Tailored Designing effective group • Of these three activities, experiences involves which would you like to try? Of consideration of individual these three route plans, which needs and strengths. The would be good for this group? benefits of healthy risk-taking Of these three things, what are optimised when should we leave behind?

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 68 experiences are tailored, What does a good leader do/ personally chosen and self- say/think/act? How will you directed by individuals within a know you’re ready to step into group context. being that? Would you like to try?

Flexible Providing genuine options and • You can use us as a resource choices for participants supports and as a cheer squad. Ask generative change. Participants us questions and tell us if benefit from opportunities you need support, we’re here to experience the direct for you. consequences of their own • If you don’t make it, or if actions, including the choice to you need to stop, that’s OK. opt out of participation or leave Stopping or saying No can be a program early. a very good decision.

Cultural Building relationships with • We’ve asked for permission local traditional custodians to be here, and want to and asking for permission show respect to the cultural before visiting a natural place custodians. Let’s spend a few demonstrates respect and minutes in silence thanking raises safety for both Aboriginal them in our own ways for their and non-Aboriginal participants care for this country. and staff. Safe OAI are culturally • Moving through here, we’re informed and responsive to the moving through someone cultural heritage of participants, else’s home. Let’s treat it with staff and places. respect and care.

Reflexive Working to increase personal • Sometimes I get nervous, self-awareness, both in the worried, angry, frustrated, tired, moment (during the work) sad, happy. It needs to be OK and retrospectively, raises for me to feel all those things, practitioner safety and and you too. It’s what I do with effectiveness. them that counts. If we can know what we’re feeling, it can help us know what to do with the feelings. • I stuffed up. Do you ever stuff up?

Responsible Safeguarding participants • When we’re ready, we’ll be and staff from physical-, able to take some good risks psychological-, social-, cultural- with each other - knowing that and environmental harms is a we’re making good decisions legal and professional duty of and looking after each other. care. • If you’re feeling unsafe in the group or during the experience, call ‘red light’. If you’re feeling unsure, call ‘orange light’. If you’re feeling safe and ready, call ‘green light’.

69 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Program design A number of studies identified the importance of program design in achieving participant outcomes, including the importance of the broad structures and components used, and the practices employed within a given model. Some descriptions of OAI with this target group focus on demographics and mechanics, such as length of program, ratios of staff to participants, the range of activities offered, and development of skills and capacity, whereas other descriptions tend to highlight the lived experience of participants, such as dealing with unfamiliar environments, the challenges, opportunities to reflect on their lives and their relationships with both the group and the facilitators. Given the focus of this review, we’ve chosen to focus on the question of how different OAI address participant safety within the task of organising information about OAI models. OAI models supporting young people who have experienced adversities span brief 1-hour interventions through to uses of extended multi-day expeditions, and residential programs that include some OAI components within a two-year model. Most OAI with young people use an outdoor adventurous multi-day journey as the primary component, with greater or lesser involvement by participants in pre- and post-journey programming. Most OAI offer interventions of one to two months with a journey of one to three weeks; very few OAI involve the participants’ wider communities in the intervention experience. The majority of OAI for young people are integrative to some extent rather than being isolated events. Some have greater or lesser links with the wider community and with participants’ existing social systems, many tend to have some connection with family members at least. Across the breadth of OAI represented in the literature, practices and programs include positivist scientific approaches and naturalistic relational approaches. Where programs are place-based, a relationship-focused and community-based approach is more often used. OAI for Aboriginal young people and delivered by Aboriginal people or culturally- aware people of European descent tend to use active outreach approaches, which involves building trusting relationships and wrapping the service around participants to meet their needs on the participant’s terms in their timing, when they are ready. Very few OAI for young people operate from a socio-ecological perspective where the service benefits both humans and the natural environment, and is part of the life of a given community. In an analysis of moderating effects across OAI Bowen & Neill (2013) stated programs were most commonly were delivered over a continuous period of time rather than intermittently, had a closed group structure with leaders and participants beginning and ending the program together, used challenge ropes courses, and involved the participant group being together 24/7 for the duration of the program, with programs ranging in length from 1 to 534 days, with 78% of programs running between 3 to 80 days in length (p.33). In a profile of Australian OAI, Bowen et al. (2016) determined that youth programs in Australia most commonly appear to include: Journeys of 2-4 days length, Adventure activities such as hiking, ropes challenge courses and

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 70 canoeing, Group activities requiring teamwork, cooperation, mutual support and communication, and Program leaders as a basis of learning. In a Churchill Fellowship Report on adventure therapy components for young people involved in offending behaviours, Pointon (2012) recommended organisations use research evidence on building resilience in young people to guide program development and follow-up planning. In this literature review, given the intention of named processes was largely unknown to us, all the smaller features, educational techniques and therapeutic practices that staff might employ during an OAI experience are called ‘processes’.

Age, gender and diversity While OAI literature tends to focus on young people, some interventions for teenagers are based on approaches that were originally developed for adults and thus not specifically designed or attuned to young people’s developmental needs (Bowen, Neil, & Crisp 2016). Bowen (2016) stated that therapeutic approaches for adolescents “should be based on an understanding of adolescent development principles, and address social, behavioural and psychological problems in a way that decreases stigma and promotes growth in competency and performance, responsibility, judgment, social orientation, motivation, and identity” (p.40). Pointon (2012) stated, “Younger participants can have excellent outcomes from attending intervention programs, provided their physical and cognitive limitations are accommodated. It is recommended that younger participants have more family/ carer involvement than older participants, as they need more support to sustain changes when they return home” (p.34). There is some evidence that the benefits for boys are greater when interventions are delivered to mixed gender groups rather than to boys alone (for example Mytton et al. 2002). However, it is not entirely clear in the OAI literature whether boys fare significantly better in mixed groups or whether the average effect is higher in mixed groups because of the presence of girls. Research relating to girls’ programs cites the benefits of female-only groups and female-only staff teams (for example Pryor et al. 2006), particularly for young women who may have experienced abuse by male/s, particularly if the abuse was recent. Flood (2006) explored the advantages and disadvantages of mixed and single gender groups for (non-OAI) interventions seeking to prevent relationship violence. He found that male-only groups helped men to feel more comfortable, less defensive, more likely to disclose, more likely to challenge each other and more likely to be more honest. However, he concluded that, for boys in particular, participation in mixed-gender groups can be very influential in improving boy’s knowledge and attitudes, and giving them the opportunity to listen to and have a dialogue with girls. Some Australian OAI supporting young people from Aboriginal and Torres Strait Islander heritage avoid highly structured models and instead offer a set of intentional processes that surround participants with a comprehensive psycho-social safety-net, where participants have higher levels of choice and decision-making and a co- participatory experience. Such methods are considered culturally appropriate within

71 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review those services, and may be appropriate for wider services supporting individual Aboriginal participants, as well as for services non-Aboriginal people (for example, Pryor, 2009). Pointon (2012) noted, “the inclusion of traditional indigenous practices and perspectives into a wilderness-based program helps give deeper meaning to the program both for indigenous and non-indigenous participants… it is also equally important that each program acknowledges and plans methods to incorporate contemporary indigenous culture where possible” (p.34). In relation to cultural diversity and culturally-aware practice, Brookes (2003) recommended that in order to achieve better explanations for what OAI can and achieve, researchers and practitioners need to: 1) attend to ‘situations’, which introduces the imperative to pay attention to specific geographical, social, political, cultural and personal circumstances; and 2) focus on programs that aim to develop ‘ongoing’ relationships’ between particular groups or individuals and specific outdoor environments. Brookes gave the example that in many Aboriginal cultures, identity and relationships are regarded as inseparable. This highlights the need for participants from place-based cultures, such as those from Aboriginal and Torres Strait cultures to experience OAI relationships that are real, authentic and lasting for them to be effective. In relation to young people who were involved in offending behaviours, and with relevance for young people who have experienced trauma, Pointon (2012) noted, “adventure therapy programs have been successfully utilised as a tool for crime prevention, as part of drug diversion and court ordered attendance to help youth with criminal convictions. In contrast, there is minimal quality research to support the use of boot camps as youth crime prevention strategy” (p.35). Her recommendation is that research be used to guide program development and follow-up planning when seeking to build resilience in young people.

Structures and components Russell and Farnum (2004) described three main structures or stages within a classic wilderness therapy program as: a cleansing phase, a personal and social responsibility phase, and a transition and aftercare phase, the authors added that programs may differ in the processes corresponding to these stages. Deane and Harré (2014) recommended OAI designers ‘Organise activities sequentially such that each task is incrementally more difficult than the previous one (p.299). In an Israeli study by Mragilt & Ben-Ari (2014) preparation meetings teach participants skills relating to basic orienteering, camping, and backpacking in order to learn about basic physical factors relating to survival and to build group social cohesion and establish group goals, as well as to check participants’ suitability to the program. The duration of the backpacking trip in the second stage of the program varies in accordance with available resources, goals, and type of population, and is generally shorter in Israel than the USA due to needing to observe the Sabbath. The two closure meetings involve processing of participants’ experiences, focusing on promoting self-efficacy and generalizing individual gains from the program into real life (pp. 82-183).

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 72 In another study by Russell (2003) the author stated, ‘Having a recognisable beginning and successful end to each task provides clear feedback about success’ (p.360). Regardless of structure, many OAI have a peak experience or main event built in. In Australia, peak experiences tend to involve journeys of 6-12 days duration, with some shorter of 3-5 days and a few shorter still, just an overnight experience. Only one Australian model uses a journey of over 30 days, a 41-day journey. In addition to journeys, a range of physical adventure activities is used. Activities include: bushwalking, camping, water-based activities such as rafting and canoeing, climbing/ abseiling, and ‘designed activities’ such as team work, initiative activities and leadership activities. Some use work-related activities, daily living skills, re-creative time such as free play and art or creative mediums, and some use animals. Many more additional activities are also used (Pryor, 2008). Baim and Guthrie (2012) listed a set of important structures to set in place for interventions with boys at risk of family violence: clear beginnings and endings and predictable routines; clear boundaries; a safe place to put belongings; involve the family and/or professionals involved in the young person’s care and protection; and an end to the process with the family/professionals involved and reflecting on the journey they have taken together (p.51). In relation to broad structures, one OAI practitioner stated, ‘The platform of change is made up of: tasks, challenges, teamwork, remoteness for growth’. Another stated, ‘The environment we attempt to offer is a ‘self-creative space’ (Pryor 2009). Such statements highlight the vastly different approaches needed in designing an effective OAI. Pryor (2009) found that there appeared to be two primary structures for Australian OAI, or rather a structured approach and a non-structured approach. Structured approaches tended to have a discrete start and end, and broadly include: a) Pre- program, b) Program, made up of Beginning, Middle, and End, and c) Post-program. A practitioner utilising a structured approach stated ‘This structure builds skills gradually enough to be achievable for most, usually all participants. The model is of significant enough duration for participants to develop strong relationships - it’s paced, and is not intense or stressful enough to bring about relapse or a ‘downer’ after the program’ (Pryor, 2009, p. 303). The following table represents a broad set of components used within typical structural approaches to OAI program design. Many programs use some but not all of these components. Some of the benefits of these components for supporting young people who have experienced adversities are provided.

73 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Figure 7. Key structures and components within OAI

Benefits for young people Structural OAI who have experienced ProgramComponents trauma and adversity

Pre-program • Promotional information Transparency/open • Worker/ family involvement communication • Taster activities Supported referral/ by a known person • Individual assessment Holistic safetynet • Group selection Voluntary participation • Orientation activities

Program Beginning Tailored individual support • Preparation activities Personal agency and • Individual goal-setting decision-making • Development of a safe group Group cohesion • Group goal-setting Sequential skill building and confidence • Training for a ‘main event’ Preparation • Departing activities

Middle A peak experience • The main event’ /The journey Tailoring of the peak experience • Additional mediums (e.g. for individuals and the group places, processes) Preparation to return • Additional activities (e.g. Supported return adventure modalities) • Additional inputs (e.g. mentors joining) • Preparing to go home activities • Landing home activities

End Safe and supported transition • Individual debriefings for individuals and the group • Group debriefing Celebration of achievements • Reinforcement of changes Public acknowledgement of efforts and changes made • Ending activities Support to transfer learning • Celebration activities • Community celebration • Public story-telling • Completion activities

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 74 Post - • Tailored follow-up Transition towards personally- program • Participant-directed chosen futures pathways Recognition of different ways • Pathways towards services individuals can create meaning, and supports purpose and belonging • Pathways towards further Further transference of learning recovery/ rehabilitation Enhanced learning • Pathways towards vocations, Opportunities for positive training, education contributions. • Pathways towards community • Further involvement in the program • Peer leadership opportunities • Program employment opportunities.

In contrast to the structured approach, a non-structured approach tends to be based on relationships rather than a chronological set of processes, tends to involve more circular processes of people coming together, moving apart, coming back together and moving apart again, perhaps perpetually within a given community. This form of program structure can be of great benefit to young people who are living in chaos and can’t meet the timelines and expectations of a structured program, along with cultural groups and communities who need greater flexibility to meet peoples’ needs. A practitioner working within this approach observed that ‘Due to chaotic (participant) lives, sometimes there is little lead-in and follow-up; so we work with who we’ve got, in ways that are useful for them’ (Pryor, 2009, p.305). Another noted, ‘Our model is not a linear process… Those boxes are OK for white, Anglo-educated people, but it doesn’t work for others’ (p.305). Another relationship-based service working with people who were living with severe depression found the word ‘salutogenesis’ useful: ‘ours is a whole approach to the person - the spiritual, psychological, the sense of everything… a health-related quality of life, influenced by experiences, beliefs, expectations and perceptions –ours is an alternative medicine in a socio-bio- geographical context [not a program]’ (p.306). Fernee et al. (2016) cited authors Wong, Greenhalgh and Pawson (2010) stating the various program components at work within OAI are unpredictable and multi- faceted, including: being in nature, being delivered by a multi-disciplinary team of practitioners, involving groups that are usually heterogeneous, and as a result, interaction of the components in a non-linear fashion to produce outcomes that are highly context dependent. In an evaluation of an OAI for young people involved in offending behaviours, Wilson and Lipsey (2000) stated, ‘’Programs involving relatively intense physical activities and therapeutic enhancements such as individual counselling, family therapy and therapeutic group sessions appear to be especially effective’ (p.10).

75 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Pointon (2012) found that involvement of families was critical for longevity of outcomes, “Familles need to be included in aspects of both the main intervention program and the follow- up as they are key components in sustaining the changes made... The different parenting styles and barriers to engagement… need to be analysed when planning how to best engage families. Depending on whether parents are overprotective or overwhelmed/ disinterested will dictate the type of engagement strategy. Geographical barriers to family engagement may mean that programs need to develop sophisticated and safe internet resources for families to access. Letters are still powerful tools for families to communicate with participants when in remote regions, and these letters need to be guided by facilitators to have maximum positive impact. Phone calls with therapists/ facilitators can also be a useful tool. However, families must have some form of buy in (emotionally, practically or financially) to maximize their engagement with the OAI” (p.34). In relation involving families, Baim and Guthrie (2012) listed a set of principles for family involvement within interventions working with boys at risk of family violence: Integrate the family into the process as much as possible; Work with the family so that they can support the young person’s changes. Work with an understanding that if only the young person changes, and the family does not, that the family system may react against the change and the young person could be at greater risk of harm to self and others. Offer ongoing treatment and support to parents and carers. A good way to do this is in group work, where parents and carers can share concerns, decrease feelings of isolation and help to support each other. Family therapy should happen concurrently with the young person’s treatment, wherever possible. Focus on the family’s needs, issues and concerns. Help the family to repair and strengthen family bonds, roles and relationships. Such sessions can also involve multiple families, where facilitators have developed skills in multi-family working (p.52). In relation to involvement of families for Indigenous young people, Pointon (2012) noted, “Engaging the wider (Indigenous) community in planning culturally appropriate outcomes for a program is a good strategy. Furthermore, celebrating the success of the participants when they return home to their community makes the program more relevant for indigenous participants” (p.34). In relation to linkages with the community, Tucker and Norton (2013) found that programs that employ specialists have a greater positive impact on participants. However, the best programs seek to improve the sustainability of outcomes by building capacity amongst those who will continue to work with and support young people in the longer term. One of the criticisms of traditional residential treatment is the limitation of removing children from the home, the cost of out-of-home care, and the limited accessibility of treatment to the individuals who may need it the most (Becker, 2010; Scott & Duerson, 2010). These authors stated that although wilderness therapy is not the same as residential treatment, the bulk of the intervention also involves out of home, non-community-based interventions that is privately funded, therefore programs for youth within community settings has been embraced by a variety of clinical professionals. For example, recent findings highlight how social workers in the United States are utilizing these techniques in school, outpatient, and healthcare settings (Tucker & Norton, 2013).

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 76 Authors Fernee et al. (2016) stated, ‘A realist understanding holds that it is not the program itself that causes change in its participants; instead, a positive outcome depends on the participants’ ability to make use of the opportunities that emerge throughout the treatment” (p.115). Within Pryor’s (2009) study of 20 Australian OAI, practitioners were also asked to consider the intentional components and strategies they have in place to support participants who have experienced risks, difficulties and traumas, and to consider their strategies across nine domains of participant wellbeing - physical, mental, emotional, behavioural, social, cultural, spiritual, environmental and economic. Responses included that special consideration be given to the following components: participant recruitment; participant assessment; group selection; case management; follow up; connections with other services and workers; and connections with local community beyond the life of the program. In a Churchill report on important OAI components, Pointon (2012) stated, “I view follow-up as an essential (and arguably the most challenging), part of a young person’s change journey. The follow-up needs to be planned carefully and be comprehensive in order to support the participants when they transition home after the intervention program. It is imperative that a follow-up program encourages family engagement and is sensitive the demographics of the participants… Further empirical research into follow-up is needed in order to compare different models of follow-up and guide Australian programs when designing or refining their follow-up service” (p.34).

Processes and activities With basic structure and core components in mind, the start of a model takes shape. The unique design of a particular service model also includes key processes and activities facilitated by staff within the program to achieve intended outcomes. These include the intentional learning and therapeutic activities woven within a program that might include wide-ranging practices, strategies, processes and activities. For young people who have experienced trauma and adversity, context and relationships have a strong impact on what will be useful for them, meaning that the particular processes and activities used by OAI staff become even more important. This is because safety and the prevention of re- traumatisation are real concerns. The review identified a range of processes that were deemed to have been effective. To a large degree they confirm that the healthy practice principles presented earlier have practical application and are supported by research evidence. Gillis, Gass and Russell (2008) mined archival data for 15,311 young offenders (males 8-18 years old) to compare 347 offenders completing a therapeutic outdoor program, 347 offenders completing a residential camping/ school program to 347 completing 90 day specialised treatment program (boot camp). The results indicated that the therapeutic outdoor program was more effective based on less rates of re arrest at the one, two and three years following release. Along with sharing household responsibilities, cleaning and cooking, setting group and individual goals, school work, adventure activities, and evaluating group and individual goals key

77 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review components of this more effective program included: • the use of group process and experiential learning • the group consisted of approximately 12–20 adolescents. • the use of specifically adventure experiences built incrementally through properly sequenced activities. • the activities were often enjoyable but not just fun, as they required skills such as patience, listening, seeing another’s point of view, leading, following, planning, and experiencing the consequences of actions. • therapeutic staff typically introduced or ‘framed’ activities around youth issues, enabling clients to experience the activity as a metaphor for their actual problem behaviours (p.234). In a widely-cited meta-analysis of 96 studies in outdoor education and adventure programming in the USA context, Hattie et al, categorised outcomes and found that in adventure programs, the highest ranking component of importance for participants is the enjoyment of nature (Hattie, Marsh, Neill & Richards, 1997). In Pryor’s Australian study of 20 OAI, over 40 practitioners were asked to describe the essential processes at work within each of mechanisms of change. Their responses included: • Processes relating to physical and natural setting: environment is organically developed by both participants and staff; novel setting –no watches or technology; must be ‘a long way away’; opportunity for connection with land, and therefore with the old ways, of the old people; time and space - longer term gives a deeper recognition of changes that take place naturally over time; being in a different place, headspace. • Processes relating to social environment: a working agreement with participants; challenge self beliefs in a safe supported environment –opportunities for changes in attitudes, beliefs, behaviours; communication, anger management content; ongoing relationships; community living; genuine care (boundaries, roles, compassion); staff - acknowledge yourself as guest, there by invitation. • Processes relating to adventure, challenge and activities: disequilibrium/ perceived risk; adventure and challenge assists change; natural consequences for choices; the experience of a wilderness walk, work at huts, and exploration of Aboriginal sites; bush-based journey (the crux); skills-based workshops (joinery, blacksmithing); physical activity, movement, body awareness, adventure, excitement. • Processes relating to therapy and intentional conversations: skilled staff (counsellors); facilitated experience; leaders as participants; non-directive experiential learning; reflection and goal setting and tailoring the experience to that. The review identified countless examples of program strategies, activities and processes that are applied within OAI to achieve intended outcomes, including those that relate easily to the four identified mechanisms of change and those that do not.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 78 An area of investigation touched on by at least one author was the question of which OAI program for which group, and which OAI program components assist which target group and individuals. According to informal interviews with practitioners, Crisp (1997) found that client factors associated with better outcomes included: the client having a physical orientation; the client having a capacity for reflection; the client having some environmental awareness; the composition of the group; families with the ability to think metaphorically (in family therapy); the recency of trauma or mental health problem; internalising disordered clients; the client having family support; the client having a greater understanding of group processes; and the client having some educational success (p.66). While the desire to have a formulaic set of structures, components, practice and processes exists, research findings demonstrated that one size does not fit all. Findings led to the decision to present a synthesis of findings in the form of program attributes that flag a safe OAI that is likely to be effective with this target group.

Attributes of safe and effective OAI program design The literature review illustrated numerous ways in which the design of OAI programs cane help to maximise safety and effectiveness: • The more personalised the program experience is, the more meaningful it will be to each participant. • The more integrated in the life of a community and a person the experience is, the more they will feel supported after the program ends. • The more tailored the pathway from OAI into other services and community settings, the more likely a healthy trajectory will be continued. • The more community partnerships involved in the OAI, the stronger the support, and the more options participants will have available after the program. • The more personally chosen an experience is, the more responsibility participants will take up. • The more ready participants are to participate, the more they will accept the challenges and lessons involved. • The more consultative and participant-led the experience, the more they will be readied to lead in other areas of their life. • The more decision-making opportunities offered to participants, the more agency and empowerment participants will carry forward after the program. • The more opportunities for leadership participants are offered within the OAI, the more ready participants will be to step up and act responsibility after the experience. • The longer the OAI, the more options and choices can be offered, and the more changes can be supported to take place. • The more space and time available to hold participants in a supportive and encouraging environment, the more they will mature into a positive trajectory. • The more engaging of participants’ bodies, minds and hearts, the more engaging of the whole person, and the more they will come to know themselves.

79 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review • The more flexible and fluid the OAI can be, the more like life it will be, and the more participants can practice regulation of their own emotions, decisions and responses. • The more an OAI is integrated into the life of a community and the close ties it has with a particular natural environment, the more likely the OAI will have a positive effect on that natural environment and nature at large.

‘What works’ is a program design that serves the specific needs of OAI individual participants within a group context.

The following table provides guidance for program design based on identified attributes of safe and effective OAI. The information is organised against AABAT’s ethical guidelines. Examples of program design strategies are offered for each attribute. By actively working towards research-informed program principles, it is likely that safety, effectiveness and empowerment for participants will be enhanced.

Table 8. Evidence-informed attributes for OAI program design

Program Principles Examples in program design

Positive Strength-based approaches • make provision for participant that recognise participants ‘self-assessment’ as experts in their own lives • include opportunities for helps avoid pathologizing or participant goal-setting and stigmatising people. decision-making • create opportunities for participants to design aspects of their intervention experience.

Tailored Catering for people's’ differing • include adults from a particular needs avoids false assumptions a culture or community and ‘formulaic’ solutions. • focus on kairos time (appropriate time) rather chronos time (clock-based time) • include greater or lesser amounts of physical activity, remove physical barriers to participation.

Integrative Including significant others and • include a ‘bring a relative’ day local community members or • invite a guest speaker from the experiences avoids brief, one- local community off or isolated OAI events. • include opportunities to volunteer at animal shelters or aged care facilities.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 80 Collaborative Promoting reciprocity and • offer ‘come and try it’ days supporting the provision of • use ‘open’ participant files, information (while maintaining where participants are able individual confidentiality) to view what has been written avoids the centralisation of about them power through withholding of • offer participants opportunities information. to understand more about program operations (e.g. letting authorities know the route plan, carrying of communications etc.).

Voluntary Including greater commitment • facilitate ‘self-selection’ based at key transition points invites on informed consent participants into greater • provide staged goal-setting commitment as they are ready, interviews, with greater levels and avoids coercion and of commitment. manipulation.

Readiness- Providing participants with • offer feeder programs based opportunities to participate • develop ‘personal readiness ‘when they are ready’, and checklists’ offering interim options if they • develop objective group are ‘not yet ready’ avoids the selection tools potential for participants to feel they are not good enough or • invite further participation. have failed.

Responsive Building in consideration of • facilitate individual interviews individual risks and goals that include personal risk and collective risks and goals assessments and development avoids treating different of risk management strategies individuals or groups in the • facilitate group goal-setting same way. • develop group agreements to support individual goals.

Holistic Developing a holistic safetynet • articulate the need for that supports people’s physical, personal responsibility and mental, emotional, behavioural, group responsibility social, cultural, spiritual, • facilitate development of group environmental and economic rules wellbeing and avoids forcing • establish clear consequences people into situations they for unsafe situations. have not chosen or are not ready for.

81 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Tailored Developing individualised • facilitate individual plans and participant-guided assessments experiences avoids ‘one size • develop tailored personal fits all’ experiences. plans • facilitate regular consultation with individuals and the group • provide flexibility for individuals to step out of group activities if needed.

Flexible Building in flexibility supports • provide opportunities for participants’ changing participant decision-making needs, and avoids coercing • program flexibility into the participants into a pre-planned program experience. • facilitate individualised exit planning.

Cultural Acknowledging cultural • ask permission to visit a place custodians (including those • pay respect to cultural who have been removed or custodians separated from a given place) • learn information to show shows respect for the cultural respect. presence in landscapes, and avoids disrespect for previous and present stewards of the land.

Reflexive Valuing skills, knowledge • provide structured and safe and increasing personal opportunities for staff to reflect awareness supports on their practice practitioner effectiveness • provide of external supervision and avoids practitioners • provide ongoing professional believing they are experts on development. the lived-experiences of their participants.

Responsible Placing importance on personal • establish program monitoring safety, group responsibility and • address fidelity and quality environmental stewardship assurance avoids delivering OAI to the • develop environmental policies detriment of any of these. and procedures.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 82 ‘What works’ are the following evidence-informed OAI attributes: Positive, Tailored, Integrative, Collaborative, Voluntary, Readiness-based, Responsive, Holistic, Tailored, Flexible, Cultural, Reflexive and Responsible.

A note on limitations The reviewed literature illustrated gaps, and many OAI evaluations left unanswered questions about which specific program components, strategies, activities and processes made a difference for participants. As a result, key mechanisms of change within many OAI remain hypothetical and are yet to be tested. Bowen (2016) stated, “Despite the growing body of research indicating that OAI can result in short- and longer-term therapeutic change, and the increased prominence of adventure therapy programs in Australia since their modern-day inception in the 1950s, there is lack of information about program designs and practice, client groups, and outcomes of Australian adventure therapy programs” (p.40). He went on to say, “Overall, despite the promising findings, more rigorous research evaluations of adventure therapy programs (e.g., quasi/experimental, case study, observational, mixed method, and longitudinal design) are needed to strengthen the reliability, validity, and usability of adventure therapy research” (p.iv). Norton et al. (2016) stated, ‘Limitations in the existing research include a lack of clearly delineated or described models of practice, a focus on program evaluation rather than rigorous intervention, research, a lack of comparison groups and longitudinal data, and a focus more on the statistical rather than clinical significance of outcomes’ (p.50). These authors went on to say, ‘Without clearly describing models and therapeutic processes used, researchers cannot be sure that the changes measured are indeed due to interventions or to other variables. This is because researchers cannot fully measure fidelity of the various models. In addition, well-documented programs are easier to replicate… There is a need for further intervention research in (OAI) to move beyond evaluation of a single program toward generalization of effectiveness to a larger populations In particular, it is important for research to compare youth with different demographic and presenting issues to see if (OAI) are more or less effective with certain populations (p.51). Gillis (2012) stressed how (OAI) research needs to move beyond a focus on statistical significance and look at the real world, practically significant, applications of our findings on client outcomes. As a ‘nearly final remark’ about the papers reviewed and the content of this report, the authors reiterate the importance of remembering to ground these findings in the historic, geographic and cultural context in which they emerged. In relation to OAI, context is significant, as is the question of what participants think, feel and experience. While a strong body of evidence supports the use of OAI with this target group, the holistic and multidimensional milieu created within an OAI makes the task of investigating mechanisms of change complex, and the task of building a coherent body of knowledge ongoing.

83 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 84 6. Key messages

• Overall, the research evidence was overwhelmingly positive in relation to the benefits of using OAI with this target group, with cautionary notes and acknowledged potential for negative outcomes. • The international field of OAI is well positioned learn more about the inner and outer workings of OAI, and about outcomes for the full range of target groups, including for younger and older people who have experienced adversities such as trauma. • The literature supported the following key mechanisms of change within OAI: 1. Experiential adventure - active participation in adventures involving physical activity and challenge (experiential adventure) - especially supportive of enhancements in participants’ biological wellbeing. 2. Therapeutic frame - intentional use of therapeutic structures, components and practices by staff and the organisation (i.e. therapy and therapeutic alliance) - especially supportive of enhancements in participants’ psychological wellbeing. 3. Positive social connections - experiences of being a member of a small supportive group (social connection and support) - especially supportive of enhancements in participants’ social wellbeing. 4. Contact with nature - time spent in nature / natural environments (passive and active nature contact) - especially supportive of enhancements in participants’ ecological and spiritual wellbeing. • Empirical evidence and a recent meta-analysis provide strong evidence for significant positive participant outcomes in areas of mental, emotional, behavioural and social wellbeing; empirical evidence relating to positive change in other areas is promising. • Given their holistic ‘environment of change’, anecdotal and theoretical evidence demonstrates that OAI have potential to impact participants across the breadth of physical, mental, emotional, behavioural, social, cultural, spiritual, environmental and economic wellbeing. • OAI provide opportunities for the enhancement of holistic wellbeing for a broad range of difficulties, and can provide immediate, medium-term and longer-term benefits for individuals. • Some examples of poor studies and poorly conceived programs were evidenced in the literature. • Cautionary notes regarding specific program components and special considerations for this target group were evidenced. • Trauma-responsive and culturally responsive OAI are likely to be safer and therefore more effective for participants whether or not they have experienced trauma or are from culturally diverse backgrounds. • Evidence-informed OAI with a clear theory of change are more likely able to minimise the risks of harm for participants and leaders.

85 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review • Given the range of program contexts and individual and group needs, OAI are expected to be built on firm evidence, but not necessarily only employ evidence- based programs or interventions. • Common characteristics were present across a range of effective OAI models supporting young people. • In synthesising findings, it was found that OAI research evidence lined up well with the ethical principles developed by the Australian Association for Bush Adventure Therapy (AABAT), therefore AABAT’s ethical principles were used as a framework to organise a newly developed set of ‘evidence-informed OAI attributes’. • The evidence-informed attributes of safe and effective OAI include programs and practitioner approaches that are: Positive, Inclusive, Integrative, Collaborative, Voluntary, Readiness-based, Responsive, Holistic, Tailored, Flexible, Cultural, Reflexive and Responsible. • Wider research supported the descriptions of these attributes, including literature relating to therapeutic interventions for young people generally, and literature relating to trauma-informed and -responsive practice. • The reality that key findings of the literature review align with previous work lends support for the list of recommended list of attributes to be used as a foundation for enhancing OAI practice and programming. • It is expected that applying this set of attributes in the development and delivery of OAI will raise levels of safety and effectiveness. • Actions in these areas will enable OAI to better support the empowerment of young people who have experienced adversities.

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Reese, R. F. & Myers, J. E. (2012). EcoWellness: The missing factor in holistic wellness models. Journal of Counselling & Development, Oct 2012(90), 400-406. Revell, S., Duncan, E., & Cooper, M. (2013). Helpful aspects of outdoor therapy experiences: An online preliminary investigation. Counselling and Psychotherapy Research, 14(4), 281-287. Rhule, D.M. (2005). Take care to do no harm: Harmful interventions for youth problem behavior. Professional Psychology: Research and Practice, 2005(36), 618-625. Ringer, M. (2002). Group Action: The dynamics of groups in therapeutic, educational and corporate settings. London: Jessica Kingsley Publishers. Ringer, M. (1998). Case studies in managing psychological depth. In Itin.C. First International Adventure Therapy Conference: Exploring the Boundaries of Adventure Therapy. Perth, WA: Camping and Outdoor Education Association of Western Australia.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 96 Roberts, S. D., Stroud, D., Hoag, M. J. & Massey, K. E. (2017). Outdoor Behavioural Health Care: A Longitudinal assessment of young adult outcomes. Journal of Counselling & Development, 95(1), 45-55. Roberts, S., Stroud, D., Hoag, M. J. & Combs, K. M. (2016). Outdoor Behavioral Healthcare: Client and treatment characteristics effects on young adult outcomes.Journal of Experiential Education, 39(3), 288-302. Roberts, S., Stroud, D., Hoag, M. J. & Massey, K. (2017). Outdoor Behavioral Healthcare: A longitudinal assessment of young adult outcomes. Journal of Counseling and Development, 95, 45-55. Romi, S. & Kohan, E. (2004). Wilderness programs: Principles, possibilities and opportunities for intervention with dropout adolescents. Child Youth Care Forum, 33(2), 115-136. Romi, S. & Kohan, E. (2004). Wilderness programs: Principles, possibilities and opportunities for intervention with dropout adolescents. Child and Youth Care Forum, 33(2), 115-136. Russell, K. C. (1999). Theoretical basis, process, and reported outcomes of wilderness therapy as an intervention and treatment for problem behavior in adolescents. Dissertation, College of Graduate Studies, University of Idaho, ID. Russell, K,C. & H. N. (2006). Incident monitoring in Outdoor Behavioural Healthcare programs: A four year summary of restraint, runaway, injury and illness Rates. Journal of Therapeutic Schools and Programs, 1(1), 70-90. Russell, K.C. (2003). An assessment of outcomes in Outdoor Behavioural Healthcare treatment. Child and Youth Care Forum, 32(6), 355-381. Russell, K. C. & Phillips-Miller, D. (2002). Perspectives on the wilderness therapy process and its relation to outcome. Child and Youth Care Forum, 31(6), 415-437. Russell, K. C. & Farnum, J. (2004). A concurrent model of the wilderness therapy process. Journal of Adventure Education & Outdoor Learning, 4(1), 39-55. Russell, K. C. (2005). Two years later: A qualitative assessment of youth well-being and the role of aftercare in outdoor behavioural healthcare treatment. Child and Youth Care Forum, 34(3), 209-239. Russell, K. C. (2005). Preliminary results of a study examining the effects of Outdoor Behavioural Healthcare treatment on levels of depression and substance use frequency. Journal of Experiential Education, 27(3,) 305-307. Russell, K. C. (2008). Adolescent substance-use treatment: Service delivery, research on effectiveness, and emerging treatment alternatives. Journal of Groups in Addiction & Recovery, 2(2-4), 68-96. Russell, K. C. (2003). A nation-wide survey of outdoor behavioural healthcare programs for adolescents with problem behaviour. Journal of Experiential Education, 25(3) 322–331. Russell, K. (2009). Keynote address: ‘Body and Soul’. In Pryor, A., Carpenter, C., Norton, C. & Kirchner, J. (Eds.) (2012). Emerging Insights: Proceedings of the Fifth International Adventure Therapy Conference (Scotland). Russell, K. & Gillis, H. L. (2017). The Adventure Therapy Experience Scale: The psychometric properties of a scale to measure the unique factors moderating an adventure therapy experience. Journal of Experiential Education, 40(2), 135-152. Russell, K. C., Gillis, H. L. 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, M. S., Widmer, M. A., Lundberg, N& Ward, P. (2015). Adaptation of an Adolescent Coping Assessment for therapeutic recreation and outdoor adventure settings. Therapeutic Recreation Journal Vol.49(1). Russell, K. C., Gillis, H. L., & Lewis, T. G. (2008). A five-year follow-up of a survey of North American Outdoor Behavioral Healthcare programs. Journal of Experiential Education, 31(1), 55-77. Scheinfeld, D. E., Rochlen, A. B. & Buser, S. J. (2011). Adventure therapy: A supplementary group therapy approach for men. Psychology of Men & Masculinity, 12(2), 188-194.

97 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Schell, L., Cotton, S. & Luxmoore, M. (2012). Outdoor adventure for young people with a mental illness. Early Intervention in Psychiatry, 6(4), 407-414. Scott, D., Salvaron, M., Reimer, E., Nichols, S., Sivak, L. &d Arney, F. (2007). Positive partnerships with parents of young children. West Perth, Western Australia: Australian Research Alliance for Children and Youth. Scozzaro, C. & Janikowski, T. (2015). Mental health diagnosis, medication, treatment and placement milieu of children in foster care. Journal of Child and Family Studies, 24(9), 2560-2567. Shanahan, L., McAllister, L. & Curtin, M. (2009). Wilderness adventure therapy and cognitive rehabilitation: Joining forces for youth with TBI. Brain Injury, 23(13/14), 1054-1064. Skouteris, H., O’Connor, A. & Cox, R. (2014.). Outdoor Adventure Experiences for Adolescents: Systematic Literature Review. Berry Street Victoria, Australia. Somervell, J. & Lambie, I. (2009). Wilderness therapy within an adolescent sexual offender treatment programme: A qualitative study. Journal of Sexual Aggression, 15(2), 161-177. Sprenkle, D. H., Davis, S. D. & Lebow, J. L. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York, NY: Guilford Press. Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration, USA.

Substance Abuse and Mental Health Services Administration. (2014). Behavioural Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. Department of Health and Human Services, USA. Thamuku, M. & Daniel, M. (2013). Exploring responses to transformative group therapy for orphaned children in the context of mass orphaning in Botswana. Death Studies, 37(5)- 413-447. Tucker, A., Massey Combs, K., Bettman, J.E., Chang, T., Graham, S., Hoag, M. & Tatum, C. (2016). Longitudinal outcomes for youth transported to wilderness therapy programs. Research on Social Work Practice, 28(4), 438-451. Tucker, A., Norton, C. L., DeMille, S. M., & Hobson, J. (2015). The impact of wilderness therapy: Utilizing an integrated care approach. Journal of Experiential Education, 39(1), 15-30. Tucker, A.R., Norton, C.L., DeMille, S., & Hobson. (2016). The impact of wilderness therapy on physical and emotional health: Utilizing an integrated approach in Outdoor Behavioral Healthcare. Journal of Experiential Education, 39(1), 15-30. Tucker, A. R., Smith, A., & Gass, M. A. (2014). How presenting problems and individual characteristics impact successful treatment outcomes in residential and wilderness treatment programs. Residential Treatment for Children & Youth, 31(2), 135-153. Tucker, A. R., Bettmann, J. E., Norton, C. L., & Comart, C. (2015). The role of transport use in adolescent wilderness tTreatment: Its relationship to readiness to change and outcomes. Child and Youth Care Forum, 44(5), 671-686. Tucker, A. R., Javorski, S., Tracy, J. & Beale, B. (2013). The use of adventure therapy in community-based mental health: Decreases in problem severity among youth clients. Child and Youth Care Forum, 42(2), 155-179. Tucker, A. R., Norton, C. L., Itin, C., Hobson, J., & Alvarez, M. A. (2016). Adventure therapy: Nondeliberative group work in action. Social Work with Groups, 39(2-3), 194-207. Tucker, A. R., & Norton, C. L. (2013). The use of adventure therapy techniques by clinical social workers: Implications for practice and training. Clinical Social Work Journal, 41(4), 333-343. Tucker, A., Paul, M., Hobson. J., Karoff, M., & Gass, M. (2016). Outdoor Behavioral Healthcare: Its impact on family functioning. Journal of Therapeutic Schools and Programs, 8, 21-40. Tucker, A., Widmer, M., Faddis, T., Randolph, B., & Gass, M. (2016). Family therapy in Outdoor Behavioral Healthcare: Current practices and future possibilities. Contemporary Family Therapy, 38, 32-42.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 98 Vermeylen, K. (2008). The triangle “anxiety-longing-pattern”: Facilitating change from an experiential- existential viewpoint. Outward Bound, Belgium. VicHealth - Victorian Health Promotion Foundation. (2005). A plan for action 2005-2007: Promoting mental health and wellbeing. Melbourne: Victorian Health Promotion Foundation, Australia. Wall, L., Higgins, D. & Hunter, C. (2016). Trauma informed care in child/family welfare services. Australian Institute of Family Studies, Child Family Community Australia. CFCA Paper No. 37. Retrieved 10 Oct 2017 from: https://aifs.gov.au/cfca/publications/trauma-informed-care-child-family-welfare-services. Walsh, M. A. & Russell, K. C. (2010). An exploratory study of a wilderness adventure program for young offenders.Ecopsychology, 2(4), 221-229. Wendell, N. S. (2004). Wilderness therapy as a viable treatment for emotionally and behaviourally disturbed children and adolescents. Dissertation. The School of Psychology, Spalding University. UMI: 3133704. West, S. & Crompton, J. (2001). Programs that work: A review of the impact of adventure programs on at-risk youth. Journal of Park and Recreation Administration, Vol. 19(2), 113-140. Williams, I. (2004). Adventure therapy or therapeutic adventure? In Bandoroff, S. & Newes, S. (Eds.). Coming of Age: The evolving field of adventure therapy. Boulder, CO, USA: Association for Experiential Education, 195-208.

Williams, I. R. (2009). Depression prevention and promotion of emotional wellbeing in adolescents using a therapeutic outdoor adventure intervention: Development of a best practice model. Dissertation, Department of Psychology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne.

Williams, I. R. & Allen, N. B. (2012). National Survey of Australian Outdoor Youth Programs: Summary report April 2012. Murdoch Children’s Research Institute, Melbourne, Australia. Willis, A. (2011). Re-storying wilderness and adventure therapies: Healing places and selves in an era of environmental crises. Journal of Adventure Education & Outdoor Learning, 11(2), 91-108. Wilson, S. J.,& Lipsey, M. W. (2000). Wilderness challenge programs for delinquent youth: A meta- analysis of outcome evaluations. Evaluation and Program Planning, 23(1), 1-12. Wong, G., Greenhalgh, T. & Pawson, R. (2010). Internet-based medical education: A realist review of what works, for whom and in what circumstances. BMC Medical Education, 10(12). Zelechoski, A. D., Sharma, R., Beserra, K., Miguel, J. L., DeMarco, M. & Spinazzola, J. (2013). Traumatized youth in residential treatment settings: Prevalence, clinical presentation, treatment, and policy Implications. Journal of Family Violence, 28(7), 639-652.

99 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Appendices

Appendix 1: Recommended Reading 1. Bolt, K. L. (2016). Descending from the summit: Aftercare planning for adolescents in wilderness therapy. Contemporary Family Therapy, 38(1), 62-74. 2. Carpenter, C., Cameron, C., Cherednichenko, B. & Townsend, M. (2007). What changes? Marginalised young people’s expectations and experiences of a therapeutic adventure in nature. Paper presented at Australian Association for Research in Education. Conference, Freemantle, Western Australia. 3. Caulkins, M. C., White, D. D. & Russell, K. C. (2006). The role of physical exercise in wilderness therapy for troubled adolescent women. Journal of Experiential Education, 29(1), 18-37. 4. Conlon, C. M., Wilson, C.E, & Gaffney, P. & Stoker, M. (2018). Wilderness therapy intervention with adolescents: Exploring the process of change. Journal of Adventure Education and Outdoor Learning. DOI: 10.1080/14729679.2018.1474118. 5. Gonzalez, A. (2014). The effects of an adventure based program: Mechanisms promoting resilient outcomes among youth in transition from childhood to adulthood. Unpublished thesis. University of Colorado, Boulder, CO. 6. Harper, N.J. (2009). The relationship of therapeutic alliance to outcome in wilderness treatment. Journal of Adventure Education and Outdoor Learning. 9(1), 45-59. 7. Jansen, C. & Pawson, P. (2012). Developing ‘challenging’ young people: Honouring their authentic story. In Pryor, A. et al. (Eds.) Emerging Insights: Proceedings of the Fifth International Adventure Therapy Conference. (Edinburgh, Scotland). Prague European Science and Art Publishing. 8. Jordan, M. (2015). Nature and Therapy: Understanding counselling and psychotherapy in outdoor spaces. Routledge: New York. 9. Knowles, B. (2013). Journeys in the bush. International Journal of Narrative Therapy & Community Work, 2013(03), 39-48. 10. Nicholls, V. (2004). Busy doing nothing: Exploring the merits of inactivity within an activity-oriented wilderness therapy program. In Bandoroff, S. & Newes, S. (Eds.). Coming of Age: The evolving field of adventure therapy. Boulder, CO, USA: Association for Experiential Education (pp.172-181). 11. Norris, J. (2011). Crossing the threshold mindfully: Exploring rites of passage models in adventure therapy. Journal of Adventure Education & Outdoor Learning. 11(2), 109-126. 12. Norton, C.L. & Peyton, J. (2017). Mindfulness-based practice in Outdoor Behavioral Healthcare. Journal of Therapeutic Schools and Programs. 9(1), 7-20.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 100 Appendix 2. Important Considerations for this Target Group

Bio-psycho-social model Consideration of which paradigms, theories or practices should be applied to the work of supporting young people who have experienced adversity and trauma leads to consideration of what is influential in both the harming and healing of young people. The bio-psycho-social model of ill health states that an individual’s health and wellbeing is influenced by the interplay between a person’s biological (physiological), psychological (mental and emotional) and social (and cultural) factors or dimensions. The bio-psycho-social framework asserts that a helpful intervention will aim to support individuals across these three domains. Jackson’s (2016)5 work on childhood neglect highlights the merits of therapeutic interventions that directly address harms associated with childhood neglect (including trauma) by applying identified key mechanisms of change to address key mechanisms of harm. Her suggested targets for change and mechanisms for change are presented across the bio-psycho-social framework and appear well matched with what can be achieved through an effective OAI. The formative evaluation of GWP extended these domains to include an ecological domain, incorporating human relationships with the natural world, including spiritual dimensions of wellbeing.

Healing from trauma For van der Kolk (2005)6, Professor of Psychiatry at Boston University, trauma is the most extreme form of stress, and arises from a severely stressful incident or incidents. Where stress persists, the effects can accumulate to such a degree that an individual’s ability to meet their daily needs or perform basic tasks is disrupted. Trauma to this degree has both psychological and physical components. Post- traumatic stress disorder is characterised by chronic, ongoing all-pervading traumatic symptoms, evident in the experience and coping strategies of victims. van der Kolk states that the treatment of childhood trauma, abuse and neglect needs to focus on three primary areas: establishing safety and competence; dealing with traumatic re-enactments, and integration and mastery of the body and mind (van der Kolk, 2005). In attempting to offer a therapeutic milieu to support people who have experienced trauma in early life, van der Kolk (2005) believes the intervention requires: • an experience of safety • the opportunity for demonstrating competence • an experience of dealing with traumatic re-enactments in positive ways • a physical experience of mastery, including the feeling of ‘being in charge, calm, and able to engage in focused efforts to accomplish goals’, and

5 Jackson, A. (2016). Childhood neglect: Beyond trauma theory - mechanisms of harm and hope for recovery. Conference poster. Berry Street Childhood Institute. 6 Van der Kolk, B.A. (2005). Developmental Trauma Disorder, Psychiatric Annals. 401-408.

101 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review • neutral fun tasks and physical games to provide the knowledge of what it feels like to be relaxed and to feel a sense of physical mastery. The capacity for OAI to relatively easily achieve all of the above requirements is clear.

Neurodevelopmental perspectives Perry’s (19947) neurodevelopmental research and theories can be seen to explain the complex and wide-ranging presentations in children and young people who have experienced child abuse, neglect and trauma. Perry posits that the timing of maltreatment experiences has implications for impacts and therapeutic interventions, and that supportive environments with consistent, safe, nurturing and enriching care (with as many quality relational interactions as possible), combined with neurodevelopmentally tailored therapeutic approaches can not only assist a child or young person’s functioning ‘in the moment’, but can also assist neurodevelopmental recovery or ‘catch up’. Perry stated that specific behavioural approaches by adults in care-giving roles can support optimal functioning of children and young people according to their arousal state at the time, whether it be a state of rest, vigilance, freeze, flight or fight (Perry 20008). For example, if a child is in a state of vigilance or hyper-vigilance, an adult may use a quiet voice, eye contact and clear simple directives to support the child’s functioning and lower their level of arousal to calm, whereas if an adult exhibits frustration, communicates from a distance, uses complex directives or gives ultimatums, this is likely to increase the child’s arousal state to freeze, flight or flight. Perry developed the Neurosequential Model of Therapeutics (NMT) to assess the developmental status of the brain via taking a comprehensive history of the child’s developmental experiences (most importantly their history of receiving care by a primary caregiver) and bio-psycho-social functioning (i.e. their multiple ‘ages’) (Perry 20069). A set of brain-region-specific questions also target the functioning ad development of the four major regions of the brain. The resulting NMT map shows areas of neurodevelopmental strength and compromise in comparison to other children or young people their age, which guides the priorities of the therapeutic intervention provided. The general functions of the four areas of the brain are provided below. Alongside each area are the therapeutic priorities, and examples of strategies recommended where compromise is identified. 1. Think - Encourage abstract thought through: humour, language, arts and games 2. Feel - Facilitate socio-emotional growth through: teams, win-lose experiences, turn-taking and sharing 3. Act - Incorporate somatic-sensory integration through: large motor skills, fine motor skills and music 4. Live - Establish state regulation through: rhythmic, patterned sensory input (auditory, tactile, motor) and attuned and responsive caregiving. It is possible that this approach could be adapted for use with young people,

7 Perry, B.D. (1994). Neurobiological sequalae of childhood trauma: Post-traumatic stress disorders in children. In M. Murburg (Ed.), Catecholamine Function in Post-traumatic Stress Disorder: Emerging Concepts. Washington, D.C: American Psychiatric Press, Washington DC, 253-276. 8 Perry, B.D. (2000). The neurodevelopmental costs of adverse childhood events. In B. Geffner. (Ed.). The Cost of Child Maltreatment: Who Pays? We All Do. Haworth Press: USA. 9 Perry, B.D. (2006). Chapter 3: Applying principles of neurodevelopment to clinical work with maltreated and traumatised children. In N.Boyd Webb (Ed.). Working with Traumatised Youth in Child Welfare. The Guildford Press: NY.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 102 although this has not been tested at this time. Key findings in relation to effective program components included the importance of NMT assessments, suitable staffing, training which is both didactic and case-based, and use of tailored interventions. Based on research and practice experience, Perry indicates effective interventions need to: • be relevant - to the child’s developmental status in any given domain of function (i.e. social, emotional, cognitive and physical) • be provided in a healthy relational context, in particular for a sense of safety and predictability • be provided with sufficient repetition and duration • have some element of reward or pleasure gained from the activity or mastery achieved, and • start with simple rhythmic and repetitive activities that help regulate the brainstem before moving to target more complex areas of the brain or more conventional therapies. Again, the capacity for OAI to meet and match Perry’s stated requirements for clinical benefit are clear.

103 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Appendix 3: OAI Attributes Aligned with AABAT’s Ethical Principles

Practitioner Attributes Program design AABAT Ethic approach

1. Positive Strength-based Recognising Hold positive approaches that participants’ expertise regard for all recognise participants in finding solutions to people as experts in their their own dilemmas own lives helps avoid helps support pathologizing or participant-driven stigmatising people. change, and mobilises participants’ capacity to determine their own preferred futures.

2. Inclusive Catering for people's’ Holding a sense of Respect differing needs avoids curious fascination differences false assumptions and towards participants in culture, ‘formulaic’ solutions. with different values, gender, age, lifestyles and relational and identity patterns shows respect for diverse backgrounds and identities.

3. Integrative Including significant Involving significant Value strong others and local others and wider family and community members community members community or experiences avoids at strategic points can connections brief, one-off or isolated help to strengthen OAI events. participants’ social supports and extend program benefits.

4. Collaborative Promoting reciprocity Relating with Offer and supporting participants as partners, Transparency, the provision of practitioners can Informed information (while maintain confidentiality consent, maintaining individual while also working Confidentiality confidentiality) avoids towards genuine the centralisation informed consent, of power through shared decision- withholding of making and co-created information. solutions.

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 104 5. Voluntary Including greater Enabling group Seek voluntary commitment at key experiences to be participation transition points invites influenced by the (within the participants into needs and hopes of confines of greater commitment participating individuals service type) as they are ready, and enables genuine avoids coercion and voluntary participation. manipulation. Where participation is mandatory, such as in medical or justice settings, practitioners may work to motivate participants to opt in for their own reasons.

6. Readiness- Providing participants Working in partnership Select for based with opportunities to with potential ‘readiness’ to participate ‘when they participants and participate are ready’, and offering significant others to interim options if they decide on suitability are ‘not yet ready’ and timing of avoids the potential for participation (and to participants to feel they what level) supports are not good enough or successful engagement have failed. and commitment.

7. Responsive Building in Understanding Attend to consideration of participants’ stories individual and individual risks and enables effective group needs goals and collective consideration of and hopes risks and goals avoids individual and group treating different needs. Safe OAI are individuals or groups in trauma-informed the same way. and responsive to participants’ individual histories.

8. Holistic Developing a holistic Establishing a holistic Support safetynet that supports safetynet includes physical, people’s physical, consideration psychological, mental, emotional, of biological, and social behavioural, social, psychological, environments cultural, spiritual, sociocultural and environmental and environmental risks and economic wellbeing benefits. Participants and avoids forcing are more likely to people into situations challenge themselves they have not chosen to grow and learn in or are not ready for. healthy ways if they are grounded in feelings of safety and security.

105 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 9. Tailored Developing Designing effective Tailor individualised plans group experiences adventure and participant-guided involves consideration experiences experiences avoids of individual needs ‘one size fits all’ and strengths. The experiences. benefits of healthy risk- taking are optimised when experiences are tailored, personally chosen and self- directed by individuals within a group context.

10. Flexible Building in flexibility Providing genuine Provide supports participants’ options and choices for options and changing needs, participants supports choices and avoids coercing generative change. (including participants into a pre- Participants benefit supported planned experience. from opportunities to exits) experience the direct consequences of their own actions, including the choice to opt out of participation or leave a program early.

11. Cultural Acknowledging cultural Building relationships Respect custodians (including with local traditional cultural those who have been custodians and asking custodianship removed or separated for permission before of country from a given place) visiting a natural place shows respect for the demonstrates respect cultural presence in and raises safety landscapes, and avoids for both Aboriginal disrespect for previous and non-Aboriginal and present stewards participants and of the land. staff. Safe OAI are culturally informed and responsive to the cultural heritage of participants, staff and places.

12. Reflexive Valuing skills, Working to increase Increase self knowledge and personal self- awareness increasing personal awareness, both in and reflexive awareness supports the moment (during practice practitioner the work) and effectiveness and retrospectively, raises

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 106 avoids practitioners practitioner safety and believing they are effectiveness. experts on the lived- experiences of their participants.

13. Responsible Placing importance Safeguarding Hold safety, on personal safety, participants and prevent harms group responsibility staff from physical-, to self, others and environmental psychological-, or natural stewardship avoids social-, cultural- and environments delivering OAI to the environmental harms is detriment of any of a legal and professional these. duty of care.

107 Outdoor Adventure Interventions - Young People and Adversity: A Literature Review Appendix 4: Secondary Literature Review Search Strategy Electronic literature databases included: Ebscohost, Informit, Factiva, Psych Info and Google Scholar. Investigation of these databases involved a primary literature search (provided on pages 11-13 of the Report) along with the following additional tailored searches: adventure therapy and young people adventure therapy and at risk young people adventure therapy and out of home care adventure therapy and child protection adventure therapy and statutory orders (outdoor or adventure or experiential) and (interven* or rehab* or program) camp and (therap* or intervene* or rehab* or program or health or dev*) bush and (therap* or intervene* or rehab* or program or health or dev*) journey and (therap* or intervene* or rehab* or program or health or dev*) activ* and (therap* or intervene* or rehab* or program or health or dev*) camp and (therap* or intervene* or rehab* or program or dev*) and (mental* or social* or behav*) (country or Indigenous) and heal* (camp or bush or journey or Indigenous or active* or walkabout) and (intervene* or therap* or rehab* or program* or health) (country or land or place) and (intervene* or therap* or rehab* or program* or health) and (mental* or social* or behav*) (country or Indigenous) and heal* (adventure therapy) and change (adventure therapy) and (mental health) (outdoor* or nature or wild*) and (intervene* or therap* or rehab* or program* or health) (youth at risk) and health and nature camp and nature and health (therap*) and (camp* or intervene* or therap* or rehab* or program* or health).

Outdoor Adventure Interventions - Young People and Adversity: A Literature Review 108 www.berrystreet.org.au