The Survival of Adventure Therapy: Profession at a Crossroads

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The Survival of Adventure TherapyProfession at
a Crossroads

• Adventure Therapy Best Practices Conference
• Durham, NH
• Michael Gass
• Department of Kinesiology
• University of New Hampshire

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Adventure Tx fieldField of opportunistic
existence

• 1901 - Tent therapy at Manhattan State Hospital
  East to isolate TB patients from other patients
• 1980s - Rapid growth of challenge courses and
  training in adolescent psychiatric hospitals
  (connected to rise of inpatient psychiatry)
  (e.g., Charter Hospitals) (Michael Stratton
  fund!)
• 1990 - Expansion in number and size of wilderness
  therapy programs (e.g., formation of OBHIC in
  1999) (connected to the fall of inpatient
  psychiatry)

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Opportunisitic growth of current Wilderness
TherapyThanks to HMOs and Prozac?Past factors

• Demise of psychiatric facilities due to strength
  of insurance and pharmaceutical companies (AT
  symptom - cutting down trees and telephone poles
  of experiential therapy challenge courses
  overnight)
• Reacting to costs and sheer greed, insurance
  companies restricted length of stay to the point
  that psychiatric hospitals became strictly
  short-term, palliative treatments for acute
  suicidal patients (Santa, 2007)
• Treatment focus at the neurotransmitter level -
  introduction of Prozac in 1985 with fewer side
  effects and mood altering drug via serotonin
  level available at the synapse (Santa, 2007)

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HMOs and Prozac leftoversThen what?

• Many adolescents did not respond well to
  replacement of community based, wrap around model
  fueled by ample meds and straightforward social
  skills training
• Failure of treatment programs created era of
  desperation to era of integrated continuity of
  care and rapid increase in wilderness therapy
  programs (1995 to present)
• 18,000 young people in NATSAP programs alone in
  2005 (Santa, 2007)

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Era of Parental Desperation
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AEEs investmentParallel Process of
Accreditation

• 1990s - Expansion in number and size of
  wilderness therapy programs (e.g., formation of
  OBHIC in 1999) (connected to the fall of
  inpatient psychiatry)
• 1990 deaths of Michelle Sutton and Kristin Chase,
  1994 death of Aaron Bacon
• 1990s - Williamson Gass produce first AEE
  Accreditation standards with subsequent editions
• 1993 - First adventure program accredited

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Evolution of AEE Accreditation

• Deaths, access, fear of the loss of
  self-governance led to awareness, call to save
  the field
• AEE 24 sponsoring programs accelerated the
  decision making process with money and huge
  personal investment on many
• Make/force bottom 20 of programs to become
  better
• Preparation - went the humanistic, sharing,
  painless route
• Great spinoffs (e.g., TAPG ethical guidelines,
  books), but a case of the top 20 of programs
  getting better.
• Action - maintenance??? Believe in common good
  may only take us so far.

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Winds of Change during first week in March, 2007

• SAMHSA website next version
• Front page of Education section of the NY Times
• In War Over Teaching Reading, a U.S.-Local
  Clash
• NICE guidelines in Great Britain
• what it would take for outdoor therapy to be on
  NICE guidelines and thought the task of this is
  incredibly daunting, but as a vision for outdoor
  therapy/ outdoors. It is what we should be
  inspiring too - even if it feels like it is
  another few decades away! It is a serious agenda
  that we cannot hide from - the future of
  sustaining practice is partly hinged on this.
  Kaye Richards, 03/07/07

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Changing Paradigm

• Leaving open ended, opportunistic paradigm
• to
• Evidenced-based choice paradigm

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Choice of Drug paradigm What do you choose?

• Scientifically based evidence backing the
  effectiveness of a drug with proven results, or a
  drug that has shown no effectiveness?
• Drug that costs 400 or one that costs 1000?
• Drug that is the same no matter where you take it
  or who gives it to you, or one that does/may
  change with administration?

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Choice of Drug paradigm You choose

• One with documented, unbiased evidence, with
  multiple tests done by different researchers
• One that is cost effective (and you can afford)
• One with fidelity, or does not change with who
  administers it to you.
• Welcome to the crossroads of the
  evidenced-based practice paradigm and our source
  of flourishing and choosing the way we practice,
  or ????

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Call to moral compass

• Because that isnt where it is at its back in
  the city, back in downtown St. Louis, back in Los
  Angeles. The final test is whether your
  experience with the sacred in nature enables you
  to cope more effectively with the problems of man
  (sic). If it doesnt enable you to cope more
  effectively with the problemsthen when that
  happens by my scale of value its failed.
• Unsoeld, W. (1974) - Spiritual Values of the
  Wilderness Keynote Address, AEE Estes Park
  Keynote Why dont we stay in the Wilderness?

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Report card on AT EBP movement

• Novel, fresh ideas were funded
• Rocky Kimball comeback response
• Lack of judging paradigms in education and mental
  health professions
• Actions of TAPG??.
• No longer is this the case.

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Affects on other approaches/programsSearch for
the actual truth or outcomes of a
well-designed and effective programs

• David Barlow (APA) (2004) landmark article
• In the 1990s large amounts of money with little
  supporting evidence was invested into programs
  addressing youth and adult violence that simply
  didnt work.
• In some cases these intervention programs created
  more harm than no program at all.

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Samples of well-known, ineffective programs

• 1990s for the emergence of ineffective but
  popular programs
• (1) Gun Buyback programs - two-thirds of the guns
  turned in did not work, almost all of the people
  turning in guns had another gun at home)
• (2) Bootcamp programs (failed to provide any
  difference in juvenile recidivism outcome rates
  than standard probation programs, but were four
  times as expensive.

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Ineffective Programs continued

• (3 ) DARE programs - traditional 5th grade
  program failed to be effective in decreasing drug
  use despite the fact that by 1998 the program was
  used in 48 of American schools with an annual
  budget of over 700 million dollars (Greenwood,
  2006).
• (4) Scared Straight programs - inculcated youth
  more directly into a criminal lifestyle, actually
  leading to increases in crime by participating
  youth and required 203 in corrective programming
  to address and undo every dollar that was
  originally spent on programming.

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Evidence means more that outcomes
cost-effectiveness measures (e.g., taxes)

• With programs that work,
• can you show a bottom line net gain?
• deliver consistent, quality programs?
• Dr. Steve Aos, WSIPP
• http//www.wsipp.wa.gov/default.asp

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Future trends of prison incarceration
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WA taxpayer rates vrs. Crime rates
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March 2004 predictions on success of AT in 2010

• have documented research on what tx does and
  does not do
• have stronger risk management systems,
  particularly when screening for which program for
  which client
• have indicators (e.g., best practices,
  accreditation) of what quality programs are and
  what they are not
• match external organizations and government
  value systems

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March 2004 predictions on success of AT in 2010

• (5)adapt to be more applicable for the changing
  demographics of America
• (6)become more recognizable to the public, being
  differentiated from other applications of
  adventure programming
• (7)understand where programming fits along a
  clients continuity of care

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Building the Adventure Programming Research House

• Many parts to building a house
• Each serve critical needs (e.g., basement -
  foundation)
• One purpose of the house roof is to protect all
  of the elements of the house from the oncoming
  storm

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Elements of building a roof

• Need to build the right roof for the right
  conditions to produce the desired results
• Need the right equipment
• At the end of the project, the housing inspector
  will come to examine the roof and let you know if
  it meets established code or not

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Legacy of previous roof builders with AE
research

• One-shot efforts
• Quantoid takeover?
• Keiths 2006 SEER analysis (3 of 14 in JEE)
• limited number in AP in Education and therapy
• Self-concept based
• Limited power
• Overgeneralization
• Not only need for demonstrating effectiveness,
  but differentiating from other findings

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LEGACY Example

• Counter Jones, Lowe, and Risler (2004) found a
  wilderness camping/group home research findings
• BMtA participants possess significantly less
  recidivism over a three year period than
  participants in OTP and YDC
• Cost savings of over 150,000 per participant

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Thirteen elements of EBP AP Research

• Matches a form of Evidenced-based research
  evaluation

• Blueprints
• DOE
• SAMHSA

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Thirteen elements of EBP AP Research

• (2) Provides Case studies or clinical samples

• Illustrates actual clinical examples (especially
  in time series designs)
• Actual examples protecting client identifying
  characteristics

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Thirteen elements of EBP AP Research

• (3) Experimental Design

• RCT
• Quasi-experimental with appropriate comparison
  group(s) and equal ns
• Watch violations of test assumptions

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Thirteen elements of EBP AP Research

• (4) Benefit-Cost Analysis

• Benefit costs ratio combined
• Compared to other programs
• Understandable to clients in terms of savings
  (e.g., Aos)

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Thirteen elements of EBP AP Research

• (5) Results reporting

• Significance testing
• Effect sizes
• Benefit-cost analysis
• Other meaningful reporting structures (e.g.,
  survival curves)

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Kaplan-Myer Survival Curve Analysis for Legacy
participants over three (3) years (under review)
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Thirteen elements of EBP AP Research

• (6) Training models

• Clear
• Uniform
• Tested
• Methods of validating/certifying/ licensing
  adherence to model

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Thirteen elements of EBP AP Research

• (7) Power of research design
• - NAROPA
• - Power calculation(1-B)

• N - increase your n
• A - relax your alpha level (.10, not .05)
• R - stronger reliability
• O - one tailed (or directional test)
• P - potency of treatment is increased
• A - analysis strategy enhanced

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Thirteen elements of EBP AP Research

• (8) Proper
• Instrumentation

• the highest value in the population being
  analyzed
• possesses well established high levels of
  validity and reliability
• appropriate for client group
• strong levels of objectivity

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Thirteen elements of EBP AP Research

• (9) Cultural variability and sensitivity

• Treatment accounts for differences in SES,
• gender,
• language,
• intellectual abilities,
• cultural characteristics.

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Thirteen elements of EBP AP Research

• Treatment/
• Intervention fidelity

• Clear treatment manual available
• documenting well-defined and previously tested
  treatment/ intervention practices,
• testing procedures in place to verify maintenance
  of intervention procedures

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Thirteen elements of EBP AP Research

• (11) Background literature support

• Building off of at least two highly similar
  control group studies
• or a large series of single-case study designs
  (e.g., more than 30).

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Thirteen elements of EBP AP Research

• (12) Replication

• Treatment Program has been replicated
• different sites
• different populations

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Thirteen elements of EBP AP Research

• (12) Replication

• Treatment Program has been replicated
• different sites
• different populations

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Thirteen elements of EBP AP Research

• (13) Length of treatment effectiveness

• Gold standard of one year
• Greater length possible?
• If not one year, then six months?
• 30 days?

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What do we have to do to change the AP field in
EBP research?

• Get people in programs interested in the value of
  EBP at the level theyre at
• Get on lists
• Defend aggressively against poor research
• Learn from the AEE Accreditation Program

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What do we have to do to change the AP field in
EBP research?

• (5) Grow our own and see them as long term
  investments, knowing there will be attrition
  along the way.
• (6) Attract external researchers to conduct
  informed and powerful research on adventure
  programs
• (7) Funding

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What do we have to do to change the AP field in
EBP research?

• (8) Motivate the field to follow -
• - increased awareness,
• - enhanced and rapid decision making WILL
  happen,
• - preparations will not be a choice,
• - set up a supportive and renewing action cycle

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What do we have to do to change the AP field in
EBP research?

• (9) Create teams of success
• - researchers
• - funders
• - programmers
• (10) Current efforts follow-up

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Whats being done?

• CORE established by AEE
• REAP as the roof builders
• REAP Conference in Santa Fe on March 19-21, 2008
• Data archive funded by NATSAP

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NATSAP Data Archive

• Collect aggregate outcome information helping
  NATSAP communicate the nature and quality of
  member programs work to stake holders
  (Auchenbach Youth Self report and Child Behavior
  Checklist)
• Allow programs to access clinically relevant
  assessment info for treatment planning purposes
• Allow programs access to their own de-identified
  aggregate information for quality improvement
• Organize the data into an accessible archival
  database for additional research projects

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What stage of buy in for EBR by adventure
programs are you in?

• Awareness stage dont know what it is, unaware
  of the benefits, or the controls dictated by EBP
• Decision-making stage - weigh pros and cons, but
  remain vague about actually making changes or
  choosing for the pro side
• Preparation stage make a decision to implement
  this process, generated by a value added
  approach of sorts from a desire to have a more
  effective program or financial reasons
• Action stage partner support structure in place
  to aid continuation

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Unaware stage
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Decision making stage
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Preparation phase
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Action Stage