Outdoor Experiential Therapies: Implications for TR Practice

THERAPEUTIC RECREATION JOURNAL Vol. 35, No. 2, 107-122, 2001

Alan W. Ewert, Bryan P. McCormick, and Alison E. Voight

The outdoor environment has a long history of being a popular venue for a variety of therapeutic recreation (TR) programs. Its potential to add a unique dimension to practice has been increasingly used by many TR programs. This article provides an overview of the basic theoretical frameworks underlying outdoor experiential therapies (OET), explores related terms (e.g., Adventure Therapy), and discusses some of the implications of including OET into TR programs. Also described are specific benefits of OET, the relationship between OET and TR practice models, types of OET, and emerging trends and issues.

KEY WORDS: Experiential Activities, Adventure Activities, Outcomes, Conceptual Develop- ment, Therapeutic Modality

The outdoor environment is increasingly article will explore some of the salient features being used as a therapeutic setting with many and applications of the therapeutic uses of organizations and programs now incorporating outdoor experiential settings. We discuss rel- a variety of therapeutic modalities in outdoor evant terminology, types of outdoor experien- and wilderness experiences (Kelley, 1993; tial therapy (OET) programs, the various ben- Roberts, 1988). These modalities have been efits associated with these programs, and some referred to under a number of terms including considerations in incorporating OET activities adventure therapy, experiential therapy, chal- into therapeutic recreation (TR) programs, lenge education, and wilderness therapy. This Several assumptions have been made prior

Alan Ewert, Ph.D. is a Professor and holder of the Joel and Patricia Meier Endowed Chairship in the Department of Recreation and Park Administration at Indiana University; Bryan McCormick, Ph.D., CTRS is an Associate Professor in the same department. Alison Voight, Ph.D., CTRS is a former Visiting Assistant Professor, also in the department at Indiana University and the current SRAC representative for the State of Indiana.

Second Quarter 2001 107 to this discussion. First, it is believed that this evaluation for the population being served. discussion is both timely and relevant to the Thus, the assumption made in this paper is that TR profession as a number of programs utiliz- professional therapy programs featuring ad- ing outdoor experiential activities are now em- venture and/or outdoor activities and utilizing bedded in a variety of TR programs. To date, carefully planned assessments and interven- there has been little written about the overall tions can be used for both the amelioration of impact of these types of modalities in TR a disability or limitation, as well as for the settings (see Austin, 1999; Groff & Dattilo, optimization of overall functioning and im- 2000). proved health. Second, it is readily acknowledged that using experiential activities in outdoor settings Defining Outdoor Experiential is only one of many types of modalities that Therapies and Related the therapeutic recreation specialist (TRS) can Terminology use effectively. There also are times in which the TRS may find the use of outdoor settings A number of terms have emerged regarding and specific adventure activities to be inappro- the different types of therapeutic interventions priate, or not fully effective, depending on the in an outdoor setting (Crisp, 1998). A partial situation and the client population. listing of these terms are described as follows: The third assumption has to do with the nature of the term "therapy." Historically, Adventure Therapy many therapeutically-related programs using Adventure therapy frequently utilizes the outdoor settings and activities have served components of adventure (e.g., real or per- people who have no medically diagnosed dis- ceived risk, uncertainty of outcome, and per- ability or functional limitation. Examples of sonal decision-making) as part of its curricu- these types of programs might include those lum structure Adventure therapy refers to serving at-risk youth or adults in transition therapeutic interventions that utilize experien- (e.g., divorce, loss of employment, etc.). As a tial and risk-taking activities, that are both result, some readers may question the use of physically and emotionally challenging, and the term "therapy" with these types of popu- usually involve an outdoor setting. It should be lations. This criticism is based on the assump- noted, however, that not all adventure thera- tion that therapies are limited to a "deficit- peutic programs contain significant levels of reduction" role, and can offer nothing to risk and danger or take place in undeveloped people seeking to enhance or optimize their outdoor settings. For example, indoor climb- leisure functioning or overall health. Another ing walls and ropes courses have become an perspective suggests that therapeutic programs increasingly popular venue for some adventure can also be used with people to improve func- therapy programs. This point will be discussed tioning or seeking greater physical and/or psy- in more detail later in this paper. chological challenges regardless of the pres- Crisp (1998) suggested that adventure ther- ence or absence of a medically-diagnosed apy is effective because it employs the "dis- problem. Austin (1999) referred to this as the equilibrium" principle, as described by Nadler "actualizing" component of high-level well- and Luckner (1992). That is, clients are faced ness. Similarly, both Gass (1993) and Crisp with novel situations in which they need to (1998) have identified a concept in "adven- develop new ways of thinking and acting. For ture-based practice" that they termed "enrich- example, people who use wheelchairs and ment." The basic premise of these types of have no prior experience being lowered down programs proposing therapy continues to be a one-hundred foot cliff, will need to develop having a clearly delineated program purpose, ways to deal with this novel situation. This goals, assessment, planning, and on-going approach emulates the widely ascribed Out-

108 Therapeutic Recreation Journal ward Bound process, as originally described matically involve adventure (i.e., the deliber- by Walsh and Golins (1976), in which the ate inclusion of risk or danger) or require participant is placed in novel physical and wilderness-like environments (Ewert, McCor- social settings and is encouraged to develop a mick, & Voight, 1999). For example, taking a new set of skills and behavior in order to group of people who have developmental dis- master the situation. abilities on a backpacking trip can precipitate a variety of beneficial outcomes without involv- Wilderness Therapy ing a high degree of risk or using a wilderness- like environment. Within this context, outdoor Friese (1996) identified over 500 programs experiential therapy (OET) is defined in the that currently operate in the United States and following way: use "wilderness-type" settings for therapeutic purposes. In addition, Cooley (1998) found A treatment modality which utilizes or that over 10,000 adolescents were being emulates an outdoor setting or natural served on an annual basis by wilderness ther- environment for the purposes of reha- apy programs constituting over 33,000 user bilitation, growth, development, and en- days on the public lands and generating over hancement of a individual's physical, $60 million in annual revenues. Although wil- social and psychological well-being derness therapy has traditionally been associ- through the application of structured ated with remote and relatively isolated natural activities involving direct experience. settings, Davis-Berman and Berman (1994) (Ewert et al., 1999) suggested that any outdoor environment may offer a suitable location for therapeutic applications. Remote areas, in particular, are often A point in common with all three of the more amenable to offering a sense of change previously described therapy programs is the from "normal" living. utilization of "direct experience" for therapeutic interventions. Direct experience involves Crisp (1998) suggested that programs using the components of participant-centered ther- a wilderness-therapy orientation utilize the apy, cognitive dissonance, reality-based out- concept of "adaptation" or coping with comes, and assessment and program structure change, either in the individual's social envi- (Gass, 1993; Gillis & Bonney, 1986). ronment or physical setting. Moreover, like Participant-Centered Therapy. Clients are adventure therapy, wilderness therapy can in- often required to take action rather than simply volve the use of a residential or base-camp serve as spectators. This action is often holistic facilities, small group dynamics, and group in the sense of involving physical, social, and psychotherapy. Given these components, pro- cognitive personal resources. Thus, whether it gram outcomes often revolve around personal be participation in an adventure-based activity, change and social development. moving down a quiet trail, or engaging in a group discussion regarding how to accomplish Outdoor Experiential Therapy a particular task, the client is exposed to situ- More recently, outdoor experiential ther- ations in which he or she is encouraged to take apy (OET) has emerged as an umbrella term some form of personal action in an outdoor that encompasses the different, but related mo- setting. In addition, the individual is often dalities of wilderness therapy and adventure faced with a specific challenge such as canoe- therapy. Inherent in the term, OET, is the ing across a lake or hiking down a trail. implication that this type of therapeutic mo- Cognitive Dissonance. In OET, cognitive dality generally utilizes an outdoor setting and dissonance or the discrepancy between two direct experience but does not mandate that individually-held phenomenon, such as per- these types of therapeutic interventions auto- ceived abilities versus anticipated challenges,

Second Quarter 2001 109 is often manifested by such issues as uncer- increase levels of trust, teach clients how to tainty of outcome, the need to take risks, and cope with anxiety and fear, and deal with resolving progressively more difficult tasks unpredictable and uncertain outcomes in order (Cooper & Fazio, 1984). Usually the underly- to yield specific benefits and enhance personal ing purpose of instituting cognitive dissonance growth and development (Nadler & Luckner, in an OET situation is to create opportunities 1992). for personal growth, team-building, enhanced communication, and contrast to one's every- Comparing Attributes of OET day life (see Walsh & Golins, 1976). andTR Reality-Based Outcomes. In the OET setting, outcomes are often perceived by the cli- Not surprisingly, there are similarities and ent as being "real." That is, if the individual contrasts among the various attributes com- does not perform to a given standard or engage mon to both TR and OET. However, a clearer in a behavior that successfully achieves the picture may be seen by a direct comparison of objective, he or she will often experience di- these attributes as is depicted in Table 1. First, rect and immediate consequences (e.g., no the two approaches can be compared in terms supper because the stove wasn't started). Ba- of the structures within which they are tradi- con (1983) suggested that these types of pro- tionally practiced. OET has historically been a grams serve as metaphors for life and as such, component of agencies whose primary mission allow the participant to learn how to contend is providing outdoor experiences. As a result, with them. Moreover, the challenges and con- these programs have been associated with out- sequences facing the individual are systemat- door centers, camps, and adventure programs. ically designed to achieve the therapeutic In contrast, TR has historically been pro- goals of the program. Further, these challenges vided through health and human service agen- and consequences are based on the physical cies. As a result, TR typically exists within and psychological status of the client, the de- organizations possessing a complex and hier- sired therapeutic intentions of the program, archical administrative structure, whereas and the physical environment in which the OET programs have historically been located program is conducted. in agencies with fewer layers of administra- Assessment and Program Structure. Phys- tion. Consequently, TR programs are often ical activities are not simply "stand-alone" more likely to be integrated with other services events with little connection to treatment plans such as social work or occupational therapy, or individual needs. Rather, outdoor experien- whereas OET programs continue to be more tial therapy programs use assessment tech- "stand-alone" and episodic. niques to link clients' needs with specifically Moreover, length of contact in traditional designed physical as well as social activities OET programs has tended to be of a longer (Gillis & Bonney, 1986). The therapist is often duration than is commonly seen in TR. Client directly involved with the clients and engaged contact lasting 24 hours per day for one to in the same activities and circumstances as the three weeks is not uncommon in OET pro- client. Gass (1993) suggested that this in- grams. As a result, working conditions in OET creased accessibility to the therapist, com- programs typically require program staff to bined with the informal setting, can serve to work non-traditional schedules. Finally, the enhance client/therapist interaction, communi- type of clients served in the two types of cation patterns, and levels of "trust." Inherent programs may differ. Although practice mod- in these types of programs are the techniques els in therapeutic recreation do not restrict of group facilitation, individual feedback, per- services to any particular population, most sonal accountability, and individual risk-tak- therapeutic recreation specialists generally ing. In addition, OET programs often strive to work with clients who have identified or diag-

110 Therapeutic Recreation Journal Table 1. Attribute Comparison of OET and Therapeutic Recreation

ATTRIBUTE OET SETTING TR SETTING

Structure Location/Facility/Setting Outdoor-based Primarily health and human Camps/Climbing Walls/ service agencies Ropes Courses Integration with other More typically "stand-alone" Usually more integration programs with other therapies Work Schedule Longer workday/e.g., 10 Typically 8 hour workday days on, 4 days off, etc. Clients Often clients w/o identified Typically clients with disability; may include identified disabilities youth-at-risk, or other special interest groups Duration of client Often longer duration (e.g., Typically shorter duration several hours/days or weeks (1-3 hours); usually of continuous contact during workday Process Instructor training Variety of skills and training CTRS minimum desired needed (e.g., search and qualification rescue, risk management) Intervention Outdoor activity is the Outdoor activities are one primary modality of a variety of possible modalities Locus of decision-making Student/Instructor/Therapist Client/TRS/Medical Team Use of Risk Real and perceived risk used Used less intensively and extensively as a learning often with traditional TR vehicle interventions

nosed disabilities. In contrast, OET programs ing as well as training in a variety of helping often focus their service on clients without professions such as counseling, psychology, identified disabilities, such as individuals de- and social work. As a result of this variety, siring a greater ability to work as a member of when compared to TR, OET staff do not have a group. a uniform set of education, experiential, and In addition to comparisons of structural credentialing backgrounds. attributes (e.g., work week, location, clients), Another comparison is seen in terms of the process attributes such as staff qualifications nature of interventions. Typically, OET pro- can also differ. While training and credential- grams exclusively use outdoor activities, coming in TR is relatively uniform, with a national bined with elements of risk and/or challenge as certification program (NCTRC), OET staff of- the primary modality. In TR practice, interven- ten come from a variety of backgrounds. These tion modalities are usually more broadly may include both "outdoor leadership" train- based, with outdoor activities as only one

Second Quarter 2001 111 treatment approach among many. Conse- Adolescents and OET. OET has been par- quently, while the elements of physical risk ticularly effective with emotionally disturbed and challenge may be used in TR settings, they adolescents, youth offenders, and teenagers are typically not as integral or structurally- with substance abuse problems. As the litera- central to the treatment approach as they are in ture suggests, a vast majority of outdoor ex- OET programs. periential programs have been specifically designed for these populations (Davis-Berman & Benefits of Outdoor Experiential Berman, 1994; Kimball, 1980; Schleien et al., 1993). According to Miles (1993), exagger- Therapy ated or misguided feelings of inadequacies, Most benefits associated with OET pro- worthlessness and lack of self-esteem often grams stem from three major behavioral do- lead these individuals to rebel against, or re- mains: sociological, psychological, and phys- treat from, society. Adolescents who are not iological. The following section provides a strongly connected to positive role models, closer look at these three domains in relation- often feel they have no significant place or role ship to participation in outdoor experiential in society, which may lead to feelings of use- therapy programs. lessness (Kimball & Bacon, 1993). Proponents of OET feel that this type of treatment approach can offer an effective modality for Social Outcomes adolescents through a process of personal The Group Process. One of the most im- growth and development. Miles (1993) elabo- portant components of many OET programs is rated on this belief in his statement, "The the "group process" (Gillis, 1998; Schleien, concreteness of challenges posed by wilder- McAvoy, Lais, & Rynders, 1993). Most OET ness experiences can allow delinquents, who programs will use a group situation as a ther- usually fail to meet abstract challenges, to apeutic intervention to enhance the learning of enjoy success and consequent enhancement of specific social skills. It is during a group pro- self-image and confidence" (p. 54). cess that therapeutic interventions may en- In particular, the group process utilized in hance social skills, refine either participant- many OET programs facilitates socially favor- identified or externally-defined personality able circumstances for group cooperation, issues, and demand expository thinking to team building, group contributions, and lead- solve group problems. In some specific in- ership. In a study by Witman (1993), helping stances, the group process may also be used to and assisting others in a group outdoor adven- redirect socially inappropriate behaviors and ture activity was cited as being the most im- expose group members to certain conse- portant to adolescents in treatment. Not sur- quences based on a sequential decision-mak- prisingly, one important social benefit derived ing process. For example, the Full Value Con- from the group process commonly used in tract component of Project Adventure sets outdoor experiential programs is the opportu- specific goals to guide group decisions when nity for positive leadership roles to emerge. confronting difficult tasks or challenges For many adolescents, particularly girls, per- (Schoel, Prouty, & Radlcliffe, 1988). "The ceptions of a leadership role may not always Full Value Contract means that group mem- be regarded as important or even feasible bers agree, in advance, to work together to- (Witman, 1993). But through OET activities, ward group goals, adhere to safety and appro- the opportunities to perform leadership roles in priate group behavioral guidelines, and both outdoor experiential groups can have a posi- give and receive constructive feedback (positive impact on self-esteem and self-confi- tive and negative)" (Smith, Austin, & dence, especially for females (Levitt, 1994; Kennedy, 1996, p. 208). Humberstone & Lynch, 1991). Women as

112 Therapeutic Recreation Journal leaders and teachers in outdoor settings "gen- ities, participants are compelled to learn the art erally bring a broader, perhaps more sensitive of listening to others. They come to under- and democratic approach to the experience" stand that they can offer their own opinion (Humberstone & Lynch, p. 29). toward resolution of the group's problems, but Another important element when working they must also accept that others in the group with groups in outdoor activities is the oppor- have convictions to which they must listen and tunity for individuals to make a positive con- evaluate, as well (Schoel, Prouty, & Radcliff, tribution to the group. Skilled, professional 1988). Learning to express opinions and pro- leadership can encourage the recognition of pose compromises are parts of a developmen- everyone's effort and value to the group tal process that plays a pivotal role in effective (Schoel et al., 1988). When appropriately communication and decision-making within structured, an OET activity can allow all per- any group situation. sons in the group to contribute solutions to problems or to achieve mutual group goals. Psychological Outcomes These goals are frequently very basic, uncom- A fundamental process of self-analysis and plicated endeavors such as finding shelter, introspection will often take place for partici- helping cook the evening meal, or providing pants in outdoor experiential therapy activi- simple words of encouragement to a frustrated ties. The nature of OET activities, such as fellow group member. Caution should be wilderness trekking or camping, may initially taken to eliminate "token" contributions, bring about the evocation of long-established where, for example, a person with a physical coping mechanisms (i.e., retreating, yelling at or mental limitation is continually given small people, and/or physically fighting with some- or inconsequential tasks to perform. An exam- one). When these familiar, or long-held coping ple of this type of token contribution would be techniques no longer "work" for an individual, to give a person a lit match to toss on a pre-laid because of the challenge, perceived fears, and bundle of brush and kindling, and told he or group dynamics presented by the activity, a she has now built a fire. Genuine use of a change or modification of "old" coping re- person's "ability," not patronization or pre- sponses and behaviors must occur (Kemp & sumptions of "disability," is an effective way McCarron, 1998). For example, the individual to ensure a meaningful and productive rela- may subjugate her old coping mechanisms tionship with group members (Schleien et al., (such as yelling when she wants to eat but is 1993). not getting her way) to the needs of other The unique challenges presented with group members (e.g., waiting, without yelling group adventure or challenge activities (i.e., to eat, until everyone is in camp and in shel- initiative tasks, trust activities, etc.) allow the ter). This fundamental shift, from old to new, opportunity for participants to establish rela- or modified patterns of behavior, in response tionships and earn the respect of fellow group to the demands of the OET challenge, often members (Witman, 1993). Many activities result in significant change and growth for an cannot be accomplished without cooperation individual. The following examples briefly de- from everyone in the group. Recalcitrant par- scribe several psychological benefits that may ticipants often learn to accept that their in- result from participation in OET. volvement is essential to completing necessary Positive Impacts for Mental Health. Using tasks and accomplishing group goals. outdoor experiential activities may challenge Group Decision-Making and Communica- pre-established convictions of personality tion. Two additional benefits associated with traits. Participants are often faced with evalu- OET in a social context are group decision- ating discrepancies between their self-concept making and effective communication. During and ideal self. Positive changes affecting self- outdoor experiential or group challenge activ- esteem, self-confidence, self-determination,

Second Quarter 2001 113 and increased self-efficacy may occur as a tic interventions (i.e., group decision-making, result of group accomplishments, reflection cognitive retraining) to help redirect external, upon personal efforts, and contributions to the unstable attributions, or locus of control, to- group's success (Schleien et al., 1993; Tate & ward more stable, internal attributions (Dieser Ellis, 1997). Other studies have indicated in- & Voight, 1998). Davis-Berman & Berman creased levels of self-actualization and in- (1994) described the relationship of OET ac- creased perceptions of personal change as a tivities and the shift of locus of control for result of participation in an outdoor adventure adolescent participants: program (Vogel, 1988/89). In particular, properly directed therapeutic One of the most often discussed interventions can help resolve group problems, changes participants experience as a re- or personal performance issues, resulting in sult of outdoor adventure pursuits is an what may be perceived as "first time" personal increased feeling of responsibility for achievements. Opportunities for solitude and the events in their lives ... Many of the reflection, not often readily available for many adolescents who are participants on a individuals, may also greatly enhance or be- wilderness therapy trip might be de- stow a more positive self-image. When scribed as having an external locus of changes take place in these psychological ar- control in that they feel they are not eas, the individual gains a greater sense of responsible for the outcomes of their self-control and self-empowerment over his or actions; that is, whether or not they get her world. Several outdoor and/or challenge rewards is a function of luck, fate or programs report such findings: Project Pride powerful others. Hopefully, participa- (New Haven, CT) "brings adventure based tion in wilderness therapy changes their learning to the school setting . .. focusing in locus of control so they come to believe self awareness, self-esteem and building com- that the outcome of their actions is a munication skills" (Davis-Berman & Berman, function of effort, skill, personality or 1994, p. 96). Working with automobile acci- other internal factors [internal locus of dent victims, "the Challenge Rehabilitation control], (p. 118) program teaches clients to trust, to take risks again, and to gain a sense of control over their world . . . engaging in activities which serve to Increased Awareness/Appreciation for the enhance their self-confidence, and problem Natural Environment. When challenge activi- solving abilities ..." (Davis-Berman & Ber- ties take place in a natural environment, the man, p. 99). opportunity to develop an individual relation- Shifting Locus of Control. Internal versus ship with the outdoor world often transpires. external focus of control refers to the predis- The outdoors can allow for personal reflection position of an individual to have or not have without the distraction of modern devices. control over the events that transpire in his or These activities can foster a first time bonding her life (Iso-Ahola, 1980). Internal locus of with the environment that, heretofore, could control (or stable attributions) refers to a per- not have taken place in a familiar, more tradi- son's belief that he/she controls the events in tional therapeutic atmosphere. The opportu- his or her life, good or bad. Persons with an nity to feel a sense of belonging to an outdoor external locus of control (or unstable attribu- or natural setting is often very difficult to tions) believe the events in their lives occur achieve in our constantly changing and ex- due to luck, fate, or chance, whether they are tremely fast paced world (Kaplan & Kaplan, good or bad outcomes. Several outdoor expe- 1989). For those who have never had the riential activities, as well as some therapeutic opportunity to be in an environment that can't recreation programs, utilize specific therapeu- be readily changed or manipulated, the out-

114 Therapeutic Recreation Journal door setting may help to recapture a sense of tribute to increased, overall physical fitness. being a part of nature (Ralston, 1991). Specifically, the physiological benefits of par- Knowledge Acquisition. While there is ticipation in OET activities may include po- much discussion and debate regarding the psy- tential increases in strength and endurance, chological benefits that may be attributed to cardiovascular output, orthopedic fitness, im- involvement with OET programs, there is an- mune system functioning, endorphin levels, other related area that is often overlooked. and catecholamine levels. Additionally, partic- Outdoor experiential therapy activities may ipation in OET programs may facilitate de- provide an ideal laboratory for learning about creases in weight, anxiety and stress, sleep the natural setting as well. The outdoors pro- disturbances, hypertension, cholesterol levels, vides a myriad of opportunities to learn about and incidences for disease (Breitenstein & things in nature, including botany, ethno- Ewert, 1990). Carefully planned interventions botany, ethology, orienteering, survival skills, with clients would be warranted when seeking and ecology. "Here, the individual will extend these types of benefits, as well as medical his or her normal functioning to greater levels clearance. of achievement based on a spontaneous learn- Further research will be necessary to exam- ing process, which is determined by the inter- ine the length of programs related to the sus- action of the individual with experience" tainability and long term effects of these ben- (Crisp, 1998, p. 60). While OET's basic efits. As indicated by Ulrich, Dimberg, & premise may be therapeutic, its inherent op- Driver (1991), involvement in outdoor recre- portunity for knowledge acquisition should be ation activities or challenge activities may considered an important by-product, shown in have positive impacts of stress reduction and studies to improve school performance, physical health, but... "there is a need for achievement test scores, and creativity (Cor- research that investigates longer term psycho- dell, 1999; Breitenstein & Ewert, 1990). It physiological influences of leisure, including may also provide an avenue for continued challenge programs" (p. 87). interest and involvement in the outdoor setting In sum, it can be seen that given the struc- on an independent basis after completion or ture and components usually present in OET discharge from an OET program. programs, the benefits gleaned by involvement in these activities transcend a broad spectrum Physiological Outcomes of physical, social, and psychological-based When individuals become involved with outcomes. The recognition of these potential OET programs, whether they are in an indoor benefits have induced more and more tradi- or outdoor setting, a natural consequence of tional treatment programs to provide OET these activities can be an overall improvement structured activities for their clients. These in physical health. Related studies have re- have included, but are not limited to, cancer searched the positive benefits associated with patients and their families, people with brain physical participation in recreation and leisure injuries or severe physical and mental disabil- activities, such as cardiovascular improve- ities, and rape victims (Asher, Huffaker, & ment, reduced glucose levels, reduced fat in McNally, 1994; Bluebond-Langer et al., 1990; body mass, and increased bone and muscle Herbert, 2000; Nichols & Fines, 1995; Sahler mass (Paffenbarger, Hyde, & Dow, 1991). & Carpenter, 1989; Witman & Preskenis, Inherent in many outdoor or adventure activi- 1996). Well-planned programs, coupled with ties, such as indoor climbing centers, ropes skilled and experienced leaders pursuing spe- courses, and wilderness experiences, is the cific therapeutic interventions are the most increased demand for physical involvement likely means of achieving beneficial outcomes resulting from unique confrontations with spe- (Datillo & Murphy, 1987; McAvoy, 1987). cific tasks and challenges that can often con- Careful consideration and planning for a par-

Second Quarter 2001 115 ticular client or group of clients with regard to sense, however, ropes courses can be consid- the philosophy and tenets of a specific OET ered abstractions of the more familiar forms of program will be essential. adventure activities such as rock climbing, caving, and mountain-climbing. As a result, OET Program Structures this dimension can range from totally human- While OET programs and modalities created environments, such as indoor climbing widely vary, they can generally be character- walls, to complete wilderness settings in ized along two dimensions. The first dimen- which the influence of humans is minimized. sion is that of the inclusion of OET in the overall system of services. At one pole of this Integrating OET into TR Practice dimension, OET may serve as an adjunct to In the following section we identify how other therapies. A typical example of this OET programming might be employed in TR would be the provision of OET in traditional settings. Although there are a number of sim- health care settings where clients simulta- ilarities between the two, their attributes are neously receive other therapies, such as voca- not identical. TRSs working in settings where tional counseling, occupational therapy, phys- some of the components typical of OET pro- ical therapy, etc. At the other end of the same grams, such as risk-taking, are being em- continuum would be those programs in which ployed, may experience conflict with practice OET is the primary therapy and the compre- parameters and efforts to integrate the two hensive framework through which services are approaches. For example, administrators may provided. Examples of this end of the contin- fear increased liability due to the perception of uum would be programs such as Catherine risk typically associated with OET-type activ- Freer Survival School and the Wilderness ities. Moreover, in some settings, off-grounds Therapy Program (Davis-Berman & Berman, excursions are coming under question by 1994). third-party payers and administrators, thus The second dimension of this characteriza- making the "outdoor" component of OET tion model is represented by the nature of the more difficult to justify. environment within which programs are offered. The inclusion of this dimension recog- OET and TR Practice Models nizes that although natural environments have Recently, there has been increased discus- traditionally been the core of outdoor experi- sion within the TR literature regarding the ential therapies, aspects of the outdoor expe- development and use of practice models. rience can be emulated, or replicated from the Voelkl, Carruthers, & Hawkins (1997) stated natural environment, and provided in human- that the influence of a practice model is such created environments, thus achieving many of that it guides the overall definition of service, the same benefits previously described. For appropriate interventions, and intended out- example, Nadler and Luckner (1992) noted comes. However, as OET has developed sep- that the adventure-based learning process re- arately from TR, there may be some confusion quires physical environment characteristics as to its "fit" within therapeutic recreation such as novelty of setting and the presence of practice. Although a variety of practice models unique problem solving situations. Neither of have appeared in the literature, two of the these elements inherently requires a remote or more widely known models are the Leisure wilderness-type environment. Another exam- Ability Model (Peterson & Gunn, 1984; ple would be high-ropes courses. Although Stumbo & Peterson, 1998), and the Health many ropes courses are located in natural set- Protection/Health Promotion Model (Austin, tings, the ropes course itself is a human-cre- 1998, 1991). The following section will focus ated structure and also can be found on hos- on the potential of integrating OET with these pital grounds and college campuses. In one two practice models.

116 Therapeutic Recreation Journal Leisure Ability Model. One of the most sion, or self-destructive thoughts. Many of the widely known practice models in therapeutic previously discussed benefits of OET are di- recreation is the Leisure Ability Model rectly related to an increased sense of mastery (Stumbo & Peterson, 1998). Due to the mod- and control. By comparison, the recreation el's explicit focus on leisure functioning, inte- component of Austin's model connotes the grating OET into practice based on the Leisure re-creative aspect of activity, in which "clients Ability Model is challenging, at best. With this begin to regain their equilibrium disrupted by in mind, it would appear that the "best" fit of stressors so that they may once again resume OET would be in the "treatment" component their quest for actualization" (p. 113). of the Leisure Ability Model. Stumbo and Based on Austin's (1998) description of Peterson stated that the intent of treatment "is this recreation component, many of the activ- to eliminate, significantly improve, or teach ities within this component are designed to the client to adapt to existing functional limi- enhance clients' social and personal function- tations that hamper efforts to engage fully in ing through learning new skills, behaviors, and leisure pursuits" (p. 89). Many of the potential insights. Thus, OET may be used to facilitate outcomes of OET are focused on personal and what Austin termed "actualization." One of social development that would likely enhance the therapeutic keys in OET is the discussion the abilities of clients to successfully engage in or "processing" of activities (see previous dis- leisure pursuits. However, enhancing leisure cussion on social benefits). The intent of pro- functioning is not typically the intent of OET. cessing activities is to enhance clients' knowl- Despite this point, certain theoretical founda- edge and skills related to personal and social tions of the Leisure Ability Model are consis- functioning. As a result, OET activities that tent with OET programming. For example, are intended to enhance such qualities as per- Stumbo and Peterson listed the constructs of sonal insight, values, or interpersonal interac- learned helplessness, mastery, and internal lo- tion would ideally fit into this component of cus of control as underlying the model. In the Health Protection/Health Promotion addition, they stated that these constructs are Model. However, to the extent that OET is related to therapeutic recreation "in that the considered a therapeutic intervention, which ultimate goal of an individual's satisfying and enhances personal and interpersonal function- independent leisure lifestyle entails being in- ing as opposed to leisure functioning, it would trinsically motivated, having an internal locus appear to fit best within practice models that of control, and feeling a sense of personal strive to improve overall individual function- causality" (p. 86). OET programs often di- ing as a final goal. rectly address improving these and similar attributes (see section on benefits of OET) and Integrating OET into TR Practice is relatively consistent with the Leisure Ability For any type of therapeutic intervention to Model. be successful, such as group interaction, one- Health Protection/Promotion Model. An- to-one therapy, counseling, leisure education, other well known practice model of therapeu- behavioral modification, cognitive retraining, tic recreation is the Health Protection/Health or role modeling, an experienced and well- Promotion Model (Austin, 1998; 1991). In this trained staff is of paramount importance in model, OET may fit within either the "pre- achieving desired outcomes. Moreover, while scriptive activity" or "recreation" components. perceptions of risk and challenge may be at the Austin stated that prescriptive activity is used heart of outdoor experiential therapies, the to energize clients who are in a state of illness. specialist must at the same time ensure that In the prescriptive activities component, OET clients are not placed in situations where their might be used to directly address threats to welfare is seriously endangered. As a result, health such as learned helplessness, depres- there are critical implications in terms of man-

Second Quarter 2001 117 aging risk when programs of this nature are gunas, 1997). Although the most obvious considered. Managing and minimizing risk has incident would be a case in which a client, staff come to be seen as a necessary attribute of member, or volunteer was injured, other inci- successful programs and instructional prac- dents in which actual practices deviate from tices (Voelkl, 1988). Therefore, the specialist standards should also be reported. Given the interested in instituting OET intervention strat- inherent risk involved in OET programming, egies needs to develop adequate plans to en- careful recording of incidents provides the CTRS sure the safety of the clients. Three basic with information that can be used to (a) docu- elements in safely managing OET are (a) the ment the safety of his/her programs, and/or (b) development of program standards, (b) injury/ provide data to investigate incidents and take incident reporting and investigation, and (c) steps to minimize risk of future incidents. clinical privileging. Clinical Privileging Program Standards Connolly (1991) stated that clinical privileging must be embraced in order to assure Increasingly, treatment protocols (cf. Fer- quality care in therapeutic recreation service. guson, 1997; Grote, Hasl, Krider, & Mortensen, The process of clinical privileging (usually 1995) are being employed to help establish conducted on an institutional basis) grants standards that guide the provision of services. therapists permission to provide client or pa- The value of treatment protocols is that they tient care services within well-defined agency set specific criteria (standards) for conducting limits, and is based upon the professional qual- an intervention. For example, the model of a ifications, competence, and abilities of the program protocol offered by Grote et al. therapist. Similarly, the role of clinical privi- (1995) includes elements such as (a) rationale leging in an OET setting is to create standards for program, (b) referral criteria, (c) key risk of competence for staff conducting OET pro- management concerns, (d) protocol criteria, grams. Given the nature of OET programs, the and (e) staff qualifications. Through the devel- competency "mix" needed by the specialist to opment of clear statements of expected proce- conduct OET will involve not only the com- dures for providing OET, the specialist can ponents of therapy but also necessitate the ensure that programs are conducted with the need for various outdoor skills such as emer- highest standards of quality and safety. In gency procedures, site management, and haz- addition, while standards of practice for ther- ard identification. Although, at present, there apeutic recreation (cf. American Therapeutic are no universal standards for conducting OET Recreation Association, 1993; National Ther- programs, a variety of training programs are apeutic Recreation Society, 1995) provide available through universities and/or private general guidelines for developing TR interven- entities such as Project Adventure, National tions, protocols for OET programs may be best Outdoor Leadership School, Outward Bound, developed using information related to adven- and the Association of Experiential Education. ture and experiential programs, such as those available from the Association for Experiential The inclusion of OET with traditional Education (Gass, 1998). health service programs should be integrated with current facility risk-management plans. Although such plans should already be in Incident Reporting and place for agencies, particularly those conduct- Investigation ing off-facility trips, the inclusion of OET into Another key to maintaining high quality and programming will require that existing plans safe programming is through the continual mon- be reviewed and revised. Particular attention itoring and reporting of incidents that are incon- should be paid to policies such as transporta- sistent with routine practice (Scott, 1994; Vana- tion, evacuation (especially if remote areas are

118 Therapeutic Recreation Journal used in programming), medications, side ef- response, search and rescue, evacuation tech- fects from natural environments (e.g., heat and niques, and other technical skills. cold stress, dehydration, and physical exer- tion), and first aid in the event of injuries. The Ethical Use of Risk and Through the use of risk management practices, Danger OET can be safely integrated into TR pro- Havens (1985) pointed out that there are a gramming while still maintaining high stan- number of ethical issues related to working dards of client safety. with clients in an outdoor setting. A sampling of these issues includes the use of danger and Issues and Trends in OET risk, pressures to participate, the safeguarding of confidential information, moral and legal A number of trends and issues that are now standards, responsibility to the client, and the impacting the OET field also have a direct welfare of the client (e.g., dealing with anxi- relationship to TR. A sample of these include ety, group confrontation, student fears, etc.). therapist or instructor training and skills, risk For example, despite the potential for personal management, the ethical use of risk and danger growth and a sense of achievement, how much in the intervention and application, third party challenge and exposure to risk are appropriate payment, and demonstrated benefits and out- for an individual client? comes from participation in OET programs. Third Party Payment Training Just as TR continues to be faced with The types and level of training therapists/ challenges associated with the third party pay- instructors need in order to be effective is ment, OET programs will experience the same highly dependent on the specific situation. For dilemma until both areas are recognized as example, how much and what type of outdoor being able to effectively deliver specific out- skills training should the TRS receive? While comes and benefits. The necessity to prove a part of this question is dependent on the type cause and effect relationship related to im- of program being implemented, there is also a proved overall functioning must transpire be- developing framework of medical, technical, fore either is likely to become a part of insured and group management skills providing a stan- and/or mandated treatment services (Shank, dardized framework for therapist/instructor Kinney, & Coyle, 1993). In addition, the use training. To a certain extent, regardless of the of OET in an actualizing or preventative situ- program and situation, the therapist/instructor ation, such as with populations "at-risk," may will need certain qualifications in outdoor pose some of the greatest challenges. This technical skills, group and individual facilita- issue will continue to pose difficulties as long tion, emergency response, risk management, as health care payment structures continue to and medical training in addition to specific be tied to pathology, as opposed to prevention. therapeutic-based training. Demonstrated Benefits and Risk Management Outcomes Because of the nature of the OET program- As previously described in this article, the ming and setting, the TR specialist will need to literature suggests that there are a number of implement effective risk management proce- benefits and positive outcomes that can be dures specific to that situation, client, and accrued from participation in outdoor experi- program. This entails understanding the com- ential programs (Ewert & McAvoy, in press). ponents of client/group coping, effective deci- However, these beneficial outcomes are pre- sion-making, hazard identification, emergency dominantly derived from a "self-system per-

Second Quarter 2001 119 spective" (i.e., self-concept, self-esteem, in- Therapeutic considerations of wilderness experi- trinsic motivation, and locus of control), as ences for incest and rape victims. Women and Ther- opposed to a physiological system. Based on apy, 75(3-4), 161-174. the research literature, little has been studied Austin, D. R. (1991). Introduction and overview. on therapeutic outcomes such as increased In D. R. Austin, and M. E. Crawford (Eds.), Ther- motor control, reduction in deviant behavior, apeutic recreation: An introduction (pp. 1-29). Englewood Cliffs, NJ: Prentice-Hall. or enhanced physical performance. Perhaps the true value of OET types of programs is that Austin, D. R. (1998). The health protection/ they are effective at impacting self-systems health promotion model. Therapeutic Recreation Journal, 32, 109-117. and affective performance, but less so in alter- ing physical parameters. Austin, D. R. (1999). Therapeutic recreation: Processes and techniques (4th Ed.). Champaign, IL: Sagamore. Conclusions Bacon, S. (1983). The conscious use of metaphor Outdoor experiential therapy programs have in Outward Bound. Denver, CO: Colorado Outward continued to grow in popularity and have moved Bound School. into the realm of normative therapeutic practices. Bluebond-Langer, M., Perkel, D., Goertzel, T., Ultimately, the role that these types of experien- Nelson, K., & McGeary, J. (1990). Children's tial treatment modalities will serve in the overall knowledge of cancer and its treatment: Impact of an scheme of TR is yet to be determined. oncology camp experience. Journal of Pediatrics, 116, 207-213. While OET programing is not a panacea nor useful in all situations, the range of its Breitenstein, D., & Ewert, A. (1990). Health applications suggests that these types of treat- benefits of outdoor recreation: Implications for ment modalities can be useful in a variety of health education. Health Education, 27(1), 16-20. settings and with a broad spectrum of clients. Bullock, C, & Mahon, M. (1997). Introduction Several critical issues, such as staff training, to recreation services for people with disabilities: A risk-taking and challenge in outdoor environ- person centered approach. Champaign, IL: Saga- more. ments, and the integration of TR program objectives with OET practices, are still to be Connolly, P. (1991). Clinical privileging: Assur- fully resolved. Moreover, how the medical ing quality performance in therapeutic recreation. In B. Riley (Ed.) Quality management: Applications community will regard OET approaches re- for therapeutic recreation (pp. 151-161). State Col- mains unanswered but probably will vary with lege, PA: Venture. the institution and situation. Cooley, R. (1998). Wilderness therapy can help This article has discussed a number of troubled teens. International Journal of Wilderness, theoretical and practice-based issues that cur- 4(3), 18-20. rently surround OET. Continued clarification Cooper, J., & Fazio, R. H. (1984). A new look at of these and related issues will serve to better dissonance theory. In L. Berkowitz (Ed), Advances identify the role that OET can play in enhanc- in experimental social psychology, Vo. 17 (pp. 229- ing the rehabilitation, functioning, and overall 262), New York: Academic Press. wellness of the client. Cordell, K. (1999). Outdoor recreation in Amer- ican life. Champaign, IL: Sagamore. Crisp, S. (1998). International models of best practice in wilderness and adventure therapy. In References C. M. Itin (Ed.), Exploring the boundaries of adven- American Therapeutic Recreation Association. ture therapy: International perspectives (pp. 56- (1993). Standards for the practice of therapeutic 74). Boulder, CO: Association of Experiential Edu- recreation & self assessment guide. Hattiesburg, cation. MS: Author. Datillo, J., & Murphy, W. D. (1987). Facilitating Asher, S., Huffaker, G., & McNally, M. (1994). the challenge in adventure recreation for persons

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