Pre-Print Available: Dissociative Mechanisms of Change in Wilderness Therapy

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Like all therapies, researchers and practitioners have made many guesses as to how and why outdoor and adventure-based therapies work. In 2018, Nevin Harper and I conducted a scoping review of published studies that tested whether the specific techniques and activities that outdoor therapy providers deliver matters.
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Some authors included in our scoping review wrote that good therapeutic outcomes come from time spent in nature. Others argued that specific activities, such as rock climbing, journaling, or group therapy led to positive outcomes. Others hypothesised that the approachable nature of outdoor therapists contributed to these outcomes. 
But what we found was interesting, though not surprising when zooming out to the wider body of psychotherapy research. Outdoor therapy services adopting specific activities didn’t have better or worse outcomes. For example, adding rock climbing or nature-based relaxation to therapeutic care didn’t make things better. 

It didn’t hurt either, for the most part. 

We could see that everything and anything appeared to have potential for therapeutic gains. 

Pathways for Change in Outdoor Therapies

Some thought this finding was troubling. “Why do outdoor therapy at all if the ‘outdoors’ doesn’t improve outcomes?” And…“How can we market our programs for funding if our activities don’t impact outcomes?”

Others found it liberating. What if the outdoors is simply another pathway to improve engagement and accessibility to effective therapeutic care. Needless to say, that paper grounds many of my adventures in research. 

Later, while researching participant experiences in wilderness therapy and America’s troubled teen industry, I kept coming back to this concept of no differences in outcomes. If we know that the specific ingredients of our outdoor work - be it hiking, meditation, gardening, surfing, or climbing - doesn’t impact outcomes at a macro level, then we must have some other rationale for why we’re using them - a story we tell ourselves to justify their use. Young people harmed in wilderness therapy described specific interventions that I believed could be removed from the practice to protect youth from harm while not impacting therapeutic quantitative outcomes (which are typically measured through standardised outcome measures, and yes…they come with their own inherent limitations). I spoke about this at conferences, receiving support from some, and accusations of misunderstanding or misrepresenting the data. 

Human Rights in Adventure Therapy

Together with my friend Graham Pringle, we started to categorise the specific interventions and practices used in wilderness therapy in the United States. We questioned where these ideas came from and why they persist despite no evidence to suggest they improved outcomes. Instead, the evidence suggested that some of these practices might be terribly harmful.

Graham jumped into this rabbit hole. He listened to hundreds of hours of wilderness therapy podcasts, read literature from the 90’s describing the theoretical foundations for wilderness therapy, and watched documentaries while taking careful timestamps of specific practices. He described these practices as coercive, and began to think of them as a dissociative mechanism of change. They were techniques used and delivered by wilderness therapy clinicians and staff to facilitate ‘therapeutic’ change. The trouble is, they seemed likely to cause  trauma responses.

Early wilderness therapy research described the importance of impelling cognitive dissonance in programs for youth. Cognitive dissonance occurs when people are faced with situations that do not confirm their expectations about who they are and how they see the world. In the right circumstances, this change in thinking can lead to positive behaviour change, such as exercising more, reducing alcohol or tobacco consumption, or prioritising a good night’s sleep. However, when outdoor therapy forces cognitive dissonance onto involuntary clients, specifically youth who are in their formative years of identity development, outcomes can be dreadful. 

We found that many wilderness therapy providers working with involuntary youth were appearing to superficially achieve good therapeutic outcomes; youth typically became compliant and participated in tasks associated with the wilderness therapy program. However, compliance does not equate to increased therapeutic engagement. Afterall, successful completion of the program, which averages 90 days in length, is the only way 94% of youth can actually leave the wilderness! 

Focusing on compliance, program completion, and “successful” treatment actually manifested like a natural trauma response that occurs when a person cannot escape a harmful experience. 

Along with scholars from the International Society for the Study of Trauma and Dissociation, and two young adults harmed as youth by America’s troubled teen industry, we drafted a paper detailing our research methodology that justifies our claim that wilderness therapy programs can deliver a potentially dissociative mechanism of change, often mistaken for an (intended) therapeutic cognitive dissonance. You can find that study here which is available to read in full in its pre-print format. 

The “Evidence”: One owner of multiple wilderness therapy and Outdoor Behavioral Healthcare programs described on a podcast placing young people in “threatening environments” which were “disorienting” and “part of the magic” of wilderness therapy. In the literature, we found proponents arguing that adventure therapy was effective at disrupting the equilibrium of a young person's life and that “change is rarely voluntary.” We watched videos of young people being blindfolded “to prevent runaways” while being involuntarily driven to the woods. When youth asked to call their parents or complained of blisters and a sore back, staff said it was “excellent acting.” 

These quotes are taken from publicly sourced material and are referenced in the article. It seemed clear that what was written in research papers was not a transparent depiction of the practices and theoretical backing informing this work. 

So back to mechanisms of change. We asked how practices with little to no research evidence supporting their positive impact on treatment outcomes continue despite the obvious contribution to dissociation, trauma responses, and harm. Are they designed to be therapeutic? If so, we have yet to hear the rationale for it. 

We invite you to join the discussion. Read the paper. Share fiercely if you’d like. Ask questions. 

Call To Action: In February 2024, a 12-year-old boy died within his first 24 hours at an accredited wilderness therapy program using practices similar to what we described in our recent study. Together with members of a community of tens of thousands of survivors from these and similar programs, we penned an open letter to the international adventure therapy community to publicly decry these practices and the associations and professionals enabling the systematic harm of youth - in the name of outdoor therapy - to continue. We hope you will sign this letter and continue advocating for safe and effective outdoor therapy. 

Above all else, we invite you to ask what specific practices in your work lead to outcomes. Have you tested them? What if a client doesn’t want to journal or meditate or walk in the woods? Who are the practices for? Author Kenneth Rosen and survivor of multiple wilderness therapy programs said during a podcast interview that adventure therapy providers are just pushing their hobbies onto their clients. An interesting, and probably mostly accurate take, so what do we do about it? 

Practitioners make evidenced, clinical judgments every day, from one experience to the next. That’s the adventure. We navigate outdoor environments and juggle our clients’ experiences in the rain, sunshine, sleet, and snow. That’s the work. 

Until next time,

​Will