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Outdoor experiential therapies: Implications for TR practice

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THERAPEUTIC
RECREATION JOURNAL Vol.
35,
No.
2,
107-122,
2001
Outdoor Experiential Therapies:
Implications for TR Practice
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
discussion is both timely and relevant to the
TR profession as a number of programs utiliz-
ing outdoor experiential activities are now em-
bedded in a variety of TR programs. To date,
there has been little written about the overall
impact of these types of modalities in TR
settings (see Austin, 1999; Groff & Dattilo,
2000).
Second, it is readily acknowledged that
using experiential activities in outdoor settings
is only one of many types of modalities that
the therapeutic recreation specialist (TRS) can
use effectively. There also are times in which
the TRS may find the use of outdoor settings
and specific adventure activities to be inappro-
priate, or not fully effective, depending on the
situation and the client population.
The third assumption has to do with the
nature of the term "therapy." Historically,
many therapeutically-related programs using
outdoor settings and activities have served
people who have no medically diagnosed dis-
ability or functional limitation. Examples of
these types of programs might include those
serving at-risk youth or adults in transition
(e.g., divorce, loss of employment, etc.). As a
result, some readers may question the use of
the term "therapy" with these types of popu-
lations. This criticism is based on the assump-
tion that therapies are limited to a "deficit-
reduction" role, and can offer nothing to
people seeking to enhance or optimize their
leisure functioning or overall health. Another
perspective suggests that therapeutic programs
can also be used with people to improve func-
tioning or seeking greater physical and/or psy-
chological challenges regardless of the pres-
ence or absence of a medically-diagnosed
problem. Austin (1999) referred to this as the
"actualizing" component of high-level well-
ness.
Similarly, both Gass (1993) and Crisp
(1998) have identified a concept in "adven-
ture-based practice" that they termed "enrich-
ment." The basic premise of these types of
programs proposing therapy continues to be
having a clearly delineated program purpose,
goals,
assessment, planning, and on-going
evaluation for the population being served.
Thus,
the assumption made in this paper is that
professional therapy programs featuring ad-
venture and/or outdoor activities and utilizing
carefully planned assessments and interven-
tions can be used for both the amelioration of
a disability or limitation, as well as for the
optimization of overall functioning and im-
proved health.
Defining Outdoor Experiential
Therapies and Related
Terminology
A number of terms have emerged regarding
the different types of therapeutic interventions
in an outdoor setting (Crisp, 1998). A partial
listing of these terms are described as follows:
Adventure Therapy
Adventure therapy frequently utilizes the
components of adventure (e.g., real or per-
ceived risk, uncertainty of outcome, and per-
sonal decision-making) as part of its curricu-
lum structure Adventure therapy refers to
therapeutic interventions that utilize experien-
tial and risk-taking activities, that are both
physically and emotionally challenging, and
usually involve an outdoor setting. It should be
noted, however, that not all adventure thera-
peutic programs contain significant levels of
risk and danger or take place in undeveloped
outdoor settings. For example, indoor climb-
ing walls and ropes courses have become an
increasingly popular venue for some adventure
therapy programs. This point will be discussed
in more detail later in this paper.
Crisp (1998) suggested that adventure ther-
apy is effective because it employs the "dis-
equilibrium" principle, as described by Nadler
and Luckner (1992). That is, clients are faced
with novel situations in which they need to
develop new ways of thinking and acting. For
example, people who use wheelchairs and
have no prior experience being lowered down
a one-hundred foot
cliff,
will need to develop
ways to deal with this novel situation. This
approach emulates the widely ascribed Out-
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Therapeutic Recreation Journal
ward Bound process, as originally described
by Walsh and Golins (1976), in which the
participant is placed in novel physical and
social settings and is encouraged to develop a
new set of skills and behavior in order to
master the situation.
Wilderness Therapy
Friese (1996) identified over 500 programs
that currently operate in the United States and
use "wilderness-type" settings for therapeutic
purposes. In addition, Cooley (1998) found
that over 10,000 adolescents were being
served on an annual basis by wilderness ther-
apy programs constituting over 33,000 user
days on the public lands and generating over
$60 million in annual revenues. Although wil-
derness therapy has traditionally been associ-
ated with remote and relatively isolated natural
settings, Davis-Berman and Berman (1994)
suggested that any outdoor environment may
offer a suitable location for therapeutic appli-
cations. Remote areas, in particular, are often
more amenable to offering a sense of change
from "normal" living.
Crisp (1998) suggested that programs using
a wilderness-therapy orientation utilize the
concept of "adaptation" or coping with
change, either in the individual's social envi-
ronment or physical setting. Moreover, like
adventure therapy, wilderness therapy can in-
volve the use of a residential or base-camp
facilities, small group dynamics, and group
psychotherapy. Given these components, pro-
gram outcomes often revolve around personal
change and social development.
Outdoor Experiential Therapy
More recently, outdoor experiential ther-
apy (OET) has emerged as an umbrella term
that encompasses the different, but related mo-
dalities of wilderness therapy and adventure
therapy. Inherent in the term, OET, is the
implication that this type of therapeutic mo-
dality generally utilizes an outdoor setting and
direct experience but does not mandate that
these types of therapeutic interventions auto-
matically involve adventure (i.e., the deliber-
ate inclusion of risk or danger) or require
wilderness-like environments (Ewert, McCor-
mick, & Voight, 1999). For example, taking a
group of people who have developmental dis-
abilities on a backpacking trip can precipitate a
variety of beneficial outcomes without involv-
ing a high degree of risk or using a wilderness-
like environment. Within this context, outdoor
experiential therapy (OET) is defined in the
following way:
A treatment modality which utilizes or
emulates an outdoor setting or natural
environment for the purposes of reha-
bilitation, growth, development, and en-
hancement of a individual's physical,
social and psychological well-being
through the application of structured
activities involving direct experience.
(Ewert et al., 1999)
A point in common with all three of the
previously described therapy programs is the
utilization of "direct experience" for therapeu-
tic interventions. Direct experience involves
the components of participant-centered ther-
apy, cognitive dissonance, reality-based out-
comes, and assessment and program structure
(Gass,
1993; Gillis & Bonney, 1986).
Participant-Centered Therapy. Clients are
often required to take action rather than simply
serve as spectators. This action is often holistic
in the sense of involving physical, social, and
cognitive personal resources. Thus, whether it
be participation in an adventure-based activity,
moving down a quiet trail, or engaging in a
group discussion regarding how to accomplish
a particular task, the client is exposed to situ-
ations in which he or she is encouraged to take
some form of personal action in an outdoor
setting. In addition, the individual is often
faced with a specific challenge such as canoe-
ing across a lake or hiking down a trail.
Cognitive Dissonance. In OET, cognitive
dissonance or the discrepancy between two
individually-held phenomenon, such as per-
ceived abilities versus anticipated challenges,
Second Quarter 2001
109
is often manifested by such issues as uncer-
tainty of outcome, the need to take risks, and
resolving progressively more difficult tasks
(Cooper & Fazio, 1984). Usually the underly-
ing purpose of instituting cognitive dissonance
in an OET situation is to create opportunities
for personal growth, team-building, enhanced
communication, and contrast to one's every-
day life (see Walsh & Golins, 1976).
Reality-Based Outcomes. In the OET set-
ting, outcomes are often perceived by the cli-
ent as being "real." That is, if the individual
does not perform to a given standard or engage
in a behavior that successfully achieves the
objective, he or she will often experience di-
rect and immediate consequences (e.g., no
supper because the stove wasn't started). Ba-
con (1983) suggested that these types of pro-
grams serve as metaphors for life and as such,
allow the participant to learn how to contend
with them. Moreover, the challenges and con-
sequences facing the individual are systemat-
ically designed to achieve the therapeutic
goals of the program. Further, these challenges
and consequences are based on the physical
and psychological status of the client, the de-
sired therapeutic intentions of the program,
and the physical environment in which the
program is conducted.
Assessment and Program Structure. Phys-
ical activities are not simply "stand-alone"
events with little connection to treatment plans
or individual needs. Rather, outdoor experien-
tial therapy programs use assessment tech-
niques to link clients' needs with specifically
designed physical as well as social activities
(Gillis & Bonney, 1986). The therapist is often
directly involved with the clients and engaged
in the same activities and circumstances as the
client. Gass (1993) suggested that this in-
creased accessibility to the therapist, com-
bined with the informal setting, can serve to
enhance client/therapist interaction, communi-
cation patterns, and levels of "trust." Inherent
in these types of programs are the techniques
of group facilitation, individual feedback, per-
sonal accountability, and individual risk-tak-
ing. In addition, OET programs often strive to
increase levels of trust, teach clients how to
cope with anxiety and fear, and deal with
unpredictable and uncertain outcomes in order
to yield specific benefits and enhance personal
growth and development (Nadler & Luckner,
1992).
Comparing Attributes of OET
andTR
Not surprisingly, there are similarities and
contrasts among the various attributes com-
mon to both TR and OET. However, a clearer
picture may be seen by a direct comparison of
these attributes as is depicted in Table 1. First,
the two approaches can be compared in terms
of the structures within which they are tradi-
tionally practiced. OET has historically been a
component of agencies whose primary mission
is providing outdoor experiences. As a result,
these programs have been associated with out-
door centers, camps, and adventure programs.
In contrast, TR has historically been pro-
vided through health and human service agen-
cies.
As a result, TR typically exists within
organizations possessing a complex and hier-
archical administrative structure, whereas
OET programs have historically been located
in agencies with fewer layers of administra-
tion. Consequently, TR programs are often
more likely to be integrated with other services
such as social work or occupational therapy,
whereas OET programs continue to be more
"stand-alone" and episodic.
Moreover, length of contact in traditional
OET programs has tended to be of a longer
duration than is commonly seen in TR. Client
contact lasting 24 hours per day for one to
three weeks is not uncommon in OET pro-
grams. As a result, working conditions in OET
programs typically require program staff to
work non-traditional schedules. Finally, the
type of clients served in the two types of
programs may differ. Although practice mod-
els in therapeutic recreation do not restrict
services to any particular population, most
therapeutic recreation specialists generally
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
Integration with other
programs
Work Schedule
Clients
Duration of client
Process
Instructor training
Intervention
Locus of decision-making
Use of Risk
Outdoor-based
Camps/Climbing Walls/
Ropes Courses
More typically "stand-alone"
Longer workday/e.g., 10
days on, 4 days off, etc.
Often clients w/o identified
disability; may include
youth-at-risk, or other
special interest groups
Often longer duration (e.g.,
several hours/days or weeks
of continuous contact
Variety of skills and training
needed (e.g., search and
rescue, risk management)
Outdoor activity is the
primary
Student/Instructor/Therapist
Real and perceived risk used
extensively as a learning
vehicle
Primarily health and human
service agencies
Usually more integration
with other therapies
Typically 8 hour workday
Typically clients with
identified disabilities
Typically shorter duration
(1-3 hours); usually
during workday
CTRS minimum desired
qualification
Outdoor activities are one
modality of a variety of
possible modalities
Client/TRS/Medical Team
Used less intensively and
often with traditional TR
interventions
nosed disabilities. In contrast, OET programs
often focus their service on clients without
identified disabilities, such as individuals de-
siring a greater ability to work as a member of
a group.
In addition to comparisons of structural
attributes (e.g., work week, location, clients),
process attributes such as staff qualifications
can also differ. While training and credential-
ing in TR is relatively uniform, with a national
certification program (NCTRC), OET staff of-
ten come from a variety of backgrounds. These
may include both "outdoor leadership" train-
ing as well as training in a variety of helping
professions such as counseling, psychology,
and social work. As a result of this variety,
when compared to TR, OET staff do not have
a uniform set of education, experiential, and
credentialing backgrounds.
Another comparison is seen in terms of the
nature of interventions. Typically, OET pro-
grams exclusively use outdoor activities, com-
bined with elements of risk and/or challenge as
the primary modality. In TR practice, interven-
tion modalities are usually more broadly
based, with outdoor activities as only one
Second Quarter 2001
111
treatment approach among many. Conse-
quently, while the elements of physical risk
and challenge may be used in TR settings, they
are typically not as integral or structurally-
central to the treatment approach as they are in
OET programs.
Benefits of Outdoor Experiential
Therapy
Most benefits associated with OET pro-
grams stem from three major behavioral do-
mains: sociological, psychological, and phys-
iological. The following section provides a
closer look at these three domains in relation-
ship to participation in outdoor experiential
therapy programs.
Social Outcomes
The Group Process. One of the most im-
portant components of many OET programs is
the "group process" (Gillis, 1998; Schleien,
McAvoy, Lais, & Rynders, 1993). Most OET
programs will use a group situation as a ther-
apeutic intervention to enhance the learning of
specific social skills. It is during a group pro-
cess that therapeutic interventions may en-
hance social skills, refine either participant-
identified or externally-defined personality
issues, and demand expository thinking to
solve group problems. In some specific in-
stances, the group process may also be used to
redirect socially inappropriate behaviors and
expose group members to certain conse-
quences based on a sequential decision-mak-
ing process. For example, the Full Value Con-
tract component of Project Adventure sets
specific goals to guide group decisions when
confronting difficult tasks or challenges
(Schoel, Prouty, & Radlcliffe, 1988). "The
Full Value Contract means that group mem-
bers agree, in advance, to work together to-
ward group goals, adhere to safety and appro-
priate group behavioral guidelines, and both
give and receive constructive feedback (posi-
tive and negative)" (Smith, Austin, &
Kennedy, 1996, p. 208).
Adolescents and OET. OET has been par-
ticularly effective with emotionally disturbed
adolescents, youth offenders, and teenagers
with substance abuse problems. As the litera-
ture suggests, a vast majority of outdoor ex-
periential programs have been specifically de-
signed for these populations (Davis-Berman &
Berman, 1994; Kimball, 1980; Schleien et al.,
1993).
According to Miles (1993), exagger-
ated or misguided feelings of inadequacies,
worthlessness and lack of self-esteem often
lead these individuals to rebel against, or re-
treat from, society. Adolescents who are not
strongly connected to positive role models,
often feel they have no significant place or role
in society, which may lead to feelings of use-
lessness (Kimball & Bacon, 1993). Proponents
of OET feel that this type of treatment ap-
proach can offer an effective modality for
adolescents through a process of personal
growth and development. Miles (1993) elabo-
rated on this belief in his statement, "The
concreteness of challenges posed by wilder-
ness experiences can allow delinquents, who
usually fail to meet abstract challenges, to
enjoy success and consequent enhancement of
self-image and confidence" (p. 54).
In particular, the group process utilized in
many OET programs facilitates socially favor-
able circumstances for group cooperation,
team building, group contributions, and lead-
ership. In a study by Witman (1993), helping
and assisting others in a group outdoor adven-
ture activity was cited as being the most im-
portant to adolescents in treatment. Not sur-
prisingly, one important social benefit derived
from the group process commonly used in
outdoor experiential programs is the opportu-
nity for positive leadership roles to emerge.
For many adolescents, particularly girls, per-
ceptions of a leadership role may not always
be regarded as important or even feasible
(Witman, 1993). But through OET activities,
the opportunities to perform leadership roles in
outdoor experiential groups can have a posi-
tive impact on self-esteem and self-confi-
dence, especially for females (Levitt, 1994;
Humberstone & Lynch, 1991). Women as
112
Therapeutic Recreation Journal
leaders and teachers in outdoor settings "gen-
erally bring a broader, perhaps more sensitive
and democratic approach to the experience"
(Humberstone & Lynch, p. 29).
Another important element when working
with groups in outdoor activities is the oppor-
tunity for individuals to make a positive con-
tribution to the group. Skilled, professional
leadership can encourage the recognition of
everyone's effort and value to the group
(Schoel et al., 1988). When appropriately
structured, an OET activity can allow all per-
sons in the group to contribute solutions to
problems or to achieve mutual group goals.
These goals are frequently very basic, uncom-
plicated endeavors such as finding shelter,
helping cook the evening meal, or providing
simple words of encouragement to a frustrated
fellow group member. Caution should be
taken to eliminate "token" contributions,
where, for example, a person with a physical
or mental limitation is continually given small
or inconsequential tasks to perform. An exam-
ple of this type of token contribution would be
to give a person a lit match to toss on a pre-laid
bundle of brush and kindling, and told he or
she has now built a fire. Genuine use of a
person's "ability," not patronization or pre-
sumptions of "disability," is an effective way
to ensure a meaningful and productive rela-
tionship with group members (Schleien et al.,
1993).
The unique challenges presented with
group adventure or challenge activities (i.e.,
initiative tasks, trust activities, etc.) allow the
opportunity for participants to establish rela-
tionships and earn the respect of fellow group
members (Witman, 1993). Many activities
cannot be accomplished without cooperation
from everyone in the group. Recalcitrant par-
ticipants often learn to accept that their in-
volvement is essential to completing necessary
tasks and accomplishing group goals.
Group Decision-Making and Communica-
tion.
Two additional benefits associated with
OET in a social context are group decision-
making and effective communication. During
outdoor experiential or group challenge activ-
ities,
participants are compelled to learn the art
of listening to others. They come to under-
stand that they can offer their own opinion
toward resolution of the group's problems, but
they must also accept that others in the group
have convictions to which they must listen and
evaluate, as well (Schoel, Prouty, &
Radcliff,
1988).
Learning to express opinions and pro-
pose compromises are parts of a developmen-
tal process that plays a pivotal role in effective
communication and decision-making within
any group situation.
Psychological Outcomes
A fundamental process of self-analysis and
introspection will often take place for partici-
pants in outdoor experiential therapy activi-
ties.
The nature of OET activities, such as
wilderness trekking or camping, may initially
bring about the evocation of long-established
coping mechanisms (i.e., retreating, yelling at
people, and/or physically fighting with some-
one).
When these familiar, or long-held coping
techniques no longer "work" for an individual,
because of the challenge, perceived fears, and
group dynamics presented by the activity, a
change or modification of "old" coping re-
sponses and behaviors must occur (Kemp &
McCarron, 1998). For example, the individual
may subjugate her old coping mechanisms
(such as yelling when she wants to eat but is
not getting her way) to the needs of other
group members (e.g., waiting, without yelling
to eat, until everyone is in camp and in shel-
ter).
This fundamental shift, from old to new,
or modified patterns of behavior, in response
to the demands of the OET challenge, often
result in significant change and growth for an
individual. The following examples briefly de-
scribe several psychological benefits that may
result from participation in OET.
Positive Impacts for Mental Health. Using
outdoor experiential activities may challenge
pre-established convictions of personality
traits.
Participants are often faced with evalu-
ating discrepancies between their self-concept
and ideal
self.
Positive changes affecting
self-
esteem, self-confidence, self-determination,
Second Quarter 2001
113
and increased self-efficacy may occur as a
result of group accomplishments, reflection
upon personal efforts, and contributions to the
group's success (Schleien et al., 1993; Tate &
Ellis,
1997). Other studies have indicated in-
creased levels of self-actualization and in-
creased perceptions of personal change as a
result of participation in an outdoor adventure
program (Vogel, 1988/89).
In particular, properly directed therapeutic
interventions can help resolve group problems,
or personal performance issues, resulting in
what may be perceived as "first time" personal
achievements. Opportunities for solitude and
reflection, not often readily available for many
individuals, may also greatly enhance or be-
stow a more positive self-image. When
changes take place in these psychological ar-
eas,
the individual gains a greater sense of
self-control and self-empowerment over his or
her world. Several outdoor and/or challenge
programs report such findings: Project Pride
(New Haven, CT) "brings adventure based
learning to the school setting . .. focusing in
self awareness, self-esteem and building com-
munication skills" (Davis-Berman & Berman,
1994,
p. 96). Working with automobile acci-
dent victims, "the Challenge Rehabilitation
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
enhance their self-confidence, and problem
solving abilities ..." (Davis-Berman & Ber-
man, p. 99).
Shifting Locus of Control. Internal versus
external focus of control refers to the predis-
position of an individual to have or not have
control over the events that transpire in his or
her life (Iso-Ahola, 1980). Internal locus of
control (or stable attributions) refers to a per-
son's belief that he/she controls the events in
his or her life, good or bad. Persons with an
external locus of control (or unstable attribu-
tions) believe the events in their lives occur
due to luck, fate, or chance, whether they are
good or bad outcomes. Several outdoor expe-
riential activities, as well as some therapeutic
recreation programs, utilize specific therapeu-
tic interventions (i.e., group decision-making,
cognitive retraining) to help redirect external,
unstable attributions, or locus of control, to-
ward more stable, internal attributions (Dieser
& Voight, 1998). Davis-Berman & Berman
(1994) described the relationship of OET ac-
tivities and the shift of locus of control for
adolescent participants:
One of the most often discussed
changes participants experience as a re-
sult of outdoor adventure pursuits is an
increased feeling of responsibility for
the events in their lives ... Many of the
adolescents who are participants on a
wilderness therapy trip might be de-
scribed as having an external locus of
control in that they feel they are not
responsible for the outcomes of their
actions; that is, whether or not they get
rewards is a function of luck, fate or
powerful others. Hopefully, participa-
tion in wilderness therapy changes their
locus of control so they come to believe
that the outcome of their actions is a
function of effort, skill, personality or
other internal factors [internal locus of
control],
(p. 118)
Increased Awareness/Appreciation for the
Natural Environment. When challenge activi-
ties take place in a natural environment, the
opportunity to develop an individual relation-
ship with the outdoor world often transpires.
The outdoors can allow for personal reflection
without the distraction of modern devices.
These activities can foster a first time bonding
with the environment that, heretofore, could
not have taken place in a familiar, more tradi-
tional therapeutic atmosphere. The opportu-
nity to feel a sense of belonging to an outdoor
or natural setting is often very difficult to
achieve in our constantly changing and ex-
tremely fast paced world (Kaplan & Kaplan,
1989).
For those who have never had the
opportunity to be in an environment that can't
be readily changed or manipulated, the out-
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Therapeutic Recreation Journal
door setting may help to recapture a sense of
being a part of nature (Ralston, 1991).
Knowledge Acquisition. While there is
much discussion and debate regarding the psy-
chological benefits that may be attributed to
involvement with OET programs, there is an-
other related area that is often overlooked.
Outdoor experiential therapy activities may
provide an ideal laboratory for learning about
the natural setting as well. The outdoors pro-
vides a myriad of opportunities to learn about
things in nature, including botany, ethno-
botany, ethology, orienteering, survival skills,
and ecology. "Here, the individual will extend
his or her normal functioning to greater levels
of achievement based on a spontaneous learn-
ing process, which is determined by the inter-
action of the individual with experience"
(Crisp, 1998, p. 60). While OET's basic
premise may be therapeutic, its inherent op-
portunity for knowledge acquisition should be
considered an important by-product, shown in
studies to improve school performance,
achievement test scores, and creativity (Cor-
dell, 1999; Breitenstein & Ewert, 1990). It
may also provide an avenue for continued
interest and involvement in the outdoor setting
on an independent basis after completion or
discharge from an OET program.
Physiological Outcomes
When individuals become involved with
OET programs, whether they are in an indoor
or outdoor setting, a natural consequence of
these activities can be an overall improvement
in physical health. Related studies have re-
searched the positive benefits associated with
physical participation in recreation and leisure
activities, such as cardiovascular improve-
ment, reduced glucose levels, reduced fat in
body mass, and increased bone and muscle
mass (Paffenbarger, Hyde, & Dow, 1991).
Inherent in many outdoor or adventure activi-
ties,
such as indoor climbing centers, ropes
courses, and wilderness experiences, is the
increased demand for physical involvement
resulting from unique confrontations with spe-
cific tasks and challenges that can often con-
tribute to increased, overall physical fitness.
Specifically, the physiological benefits of par-
ticipation in OET activities may include po-
tential increases in strength and endurance,
cardiovascular output, orthopedic fitness, im-
mune system functioning, endorphin levels,
and catecholamine levels. Additionally, partic-
ipation in OET programs may facilitate de-
creases in weight, anxiety and stress, sleep
disturbances, hypertension, cholesterol levels,
and incidences for disease (Breitenstein &
Ewert, 1990). Carefully planned interventions
with clients would be warranted when seeking
these types of benefits, as well as medical
clearance.
Further research will be necessary to exam-
ine the length of programs related to the sus-
tainability and long term effects of these ben-
efits.
As indicated by Ulrich, Dimberg, &
Driver (1991), involvement in outdoor recre-
ation activities or challenge activities may
have positive impacts of stress reduction and
physical health, but... "there is a need for
research that investigates longer term psycho-
physiological influences of leisure, including
challenge programs" (p. 87).
In sum, it can be seen that given the struc-
ture and components usually present in OET
programs, the benefits gleaned by involvement
in these activities transcend a broad spectrum
of physical, social, and psychological-based
outcomes. The recognition of these potential
benefits have induced more and more tradi-
tional treatment programs to provide OET
structured activities for their clients. These
have included, but are not limited to, cancer
patients and their families, people with brain
injuries or severe physical and mental disabil-
ities,
and rape victims (Asher, Huffaker, &
McNally, 1994; Bluebond-Langer et al., 1990;
Herbert, 2000; Nichols & Fines, 1995; Sahler
& Carpenter, 1989; Witman & Preskenis,
1996).
Well-planned programs, coupled with
skilled and experienced leaders pursuing spe-
cific therapeutic interventions are the most
likely means of achieving beneficial outcomes
(Datillo & Murphy, 1987; McAvoy, 1987).
Careful consideration and planning for a par-
Second Quarter 2001
115
ticular client or group of clients with regard to
the philosophy and tenets of a specific OET
program will be essential.
OET Program Structures
While OET programs and modalities
widely vary, they can generally be character-
ized along two dimensions. The first dimen-
sion is that of the inclusion of OET in the
overall system of services. At one pole of this
dimension, OET may serve as an adjunct to
other therapies. A typical example of this
would be the provision of OET in traditional
health care settings where clients simulta-
neously receive other therapies, such as voca-
tional counseling, occupational therapy, phys-
ical therapy, etc. At the other end of the same
continuum would be those programs in which
OET is the primary therapy and the compre-
hensive framework through which services are
provided. Examples of this end of the contin-
uum would be programs such as Catherine
Freer Survival School and the Wilderness
Therapy Program (Davis-Berman & Berman,
1994).
The second dimension of this characteriza-
tion model is represented by the nature of the
environment within which programs are of-
fered. The inclusion of this dimension recog-
nizes that although natural environments have
traditionally been the core of outdoor experi-
ential therapies, aspects of the outdoor expe-
rience can be emulated, or replicated from the
natural environment, and provided in human-
created environments, thus achieving many of
the same benefits previously described. For
example, Nadler and Luckner (1992) noted
that the adventure-based learning process re-
quires physical environment characteristics
such as novelty of setting and the presence of
unique problem solving situations. Neither of
these elements inherently requires a remote or
wilderness-type environment. Another exam-
ple would be high-ropes courses. Although
many ropes courses are located in natural set-
tings,
the ropes course itself is a human-cre-
ated structure and also can be found on hos-
pital grounds and college campuses. In one
sense, however, ropes courses can be consid-
ered abstractions of the more familiar forms of
adventure activities such as rock climbing,
caving, and mountain-climbing. As a result,
this dimension can range from totally human-
created environments, such as indoor climbing
walls,
to complete wilderness settings in
which the influence of humans is minimized.
Integrating OET into TR Practice
In the following section we identify how
OET programming might be employed in TR
settings. Although there are a number of sim-
ilarities between the two, their attributes are
not identical. TRSs working in settings where
some of the components typical of OET pro-
grams, such as risk-taking, are being em-
ployed, may experience conflict with practice
parameters and efforts to integrate the two
approaches. For example, administrators may
fear increased liability due to the perception of
risk typically associated with OET-type activ-
ities.
Moreover, in some settings, off-grounds
excursions are coming under question by
third-party payers and administrators, thus
making the "outdoor" component of OET
more difficult to justify.
OET and TR Practice Models
Recently, there has been increased discus-
sion within the TR literature regarding the
development and use of practice models.
Voelkl, Carruthers, & Hawkins (1997) stated
that the influence of a practice model is such
that it guides the overall definition of service,
appropriate interventions, and intended out-
comes. However, as OET has developed sep-
arately from TR, there may be some confusion
as to its "fit" within therapeutic recreation
practice. Although a variety of practice models
have appeared in the literature, two of the
more widely known models are the Leisure
Ability Model (Peterson & Gunn, 1984;
Stumbo & Peterson, 1998), and the Health
Protection/Health Promotion Model (Austin,
1998,
1991). The following section will focus
on the potential of integrating OET with these
two practice models.
116
Therapeutic Recreation Journal
Leisure Ability Model. One of the most
widely known practice models in therapeutic
recreation is the Leisure Ability Model
(Stumbo & Peterson, 1998). Due to the mod-
el's explicit focus on leisure functioning, inte-
grating OET into practice based on the Leisure
Ability Model is challenging, at best. With this
in mind, it would appear that the "best" fit of
OET would be in the "treatment" component
of the Leisure Ability Model. Stumbo and
Peterson stated that the intent of treatment "is
to eliminate, significantly improve, or teach
the client to adapt to existing functional limi-
tations that hamper efforts to engage fully in
leisure pursuits" (p. 89). Many of the potential
outcomes of OET are focused on personal and
social development that would likely enhance
the abilities of clients to successfully engage in
leisure pursuits. However, enhancing leisure
functioning is not typically the intent of OET.
Despite this point, certain theoretical founda-
tions of the Leisure Ability Model are consis-
tent with OET programming. For example,
Stumbo and Peterson listed the constructs of
learned helplessness, mastery, and internal lo-
cus of control as underlying the model. In
addition, they stated that these constructs are
related to therapeutic recreation "in that the
ultimate goal of an individual's satisfying and
independent leisure lifestyle entails being in-
trinsically motivated, having an internal locus
of control, and feeling a sense of personal
causality" (p. 86). OET programs often di-
rectly address improving these and similar
attributes (see section on benefits of OET) and
is relatively consistent with the Leisure Ability
Model.
Health Protection/Promotion Model. An-
other well known practice model of therapeu-
tic recreation is the Health Protection/Health
Promotion Model (Austin, 1998; 1991). In this
model, OET may fit within either the "pre-
scriptive activity" or "recreation" components.
Austin stated that prescriptive activity is used
to energize clients who are in a state of illness.
In the prescriptive activities component, OET
might be used to directly address threats to
health such as learned helplessness, depres-
sion, or self-destructive thoughts. Many of the
previously discussed benefits of OET are di-
rectly related to an increased sense of mastery
and control. By comparison, the recreation
component of Austin's model connotes the
re-creative aspect of activity, in which "clients
begin to regain their equilibrium disrupted by
stressors so that they may once again resume
their quest for actualization" (p. 113).
Based on Austin's (1998) description of
this recreation component, many of the activ-
ities within this component are designed to
enhance clients' social and personal function-
ing through learning new skills, behaviors, and
insights. Thus, OET may be used to facilitate
what Austin termed "actualization." One of
the therapeutic keys in OET is the discussion
or "processing" of activities (see previous dis-
cussion on social benefits). The intent of pro-
cessing activities is to enhance clients' knowl-
edge and skills related to personal and social
functioning. As a result, OET activities that
are intended to enhance such qualities as per-
sonal insight, values, or interpersonal interac-
tion would ideally fit into this component of
the Health Protection/Health Promotion
Model. However, to the extent that OET is
considered a therapeutic intervention, which
enhances personal and interpersonal function-
ing as opposed to leisure functioning, it would
appear to fit best within practice models that
strive to improve overall individual function-
ing as a final goal.
Integrating OET into TR Practice
For any type of therapeutic intervention to
be successful, such as group interaction, one-
to-one therapy, counseling, leisure education,
behavioral modification, cognitive retraining,
or role modeling, an experienced and well-
trained staff is of paramount importance in
achieving desired outcomes. Moreover, while
perceptions of risk and challenge may be at the
heart of outdoor experiential therapies, the
specialist must at the same time ensure that
clients are not placed in situations where their
welfare is seriously endangered. As a result,
there are critical implications in terms of man-
Second Quarter 2001
117
aging risk when programs of this nature are
considered. Managing and minimizing risk has
come to be seen as a necessary attribute of
successful programs and instructional prac-
tices (Voelkl, 1988). Therefore, the specialist
interested in instituting OET intervention strat-
egies needs to develop adequate plans to en-
sure the safety of the clients. Three basic
elements in safely managing OET are (a) the
development of program standards, (b) injury/
incident reporting and investigation, and (c)
clinical privileging.
Program Standards
Increasingly, treatment protocols (cf. Fer-
guson, 1997; Grote, Hasl, Krider, & Mortensen,
1995) are being employed to help establish
standards that guide the provision of services.
The value of treatment protocols is that they
set specific criteria (standards) for conducting
an intervention. For example, the model of a
program protocol offered by Grote et al.
(1995) includes elements such as (a) rationale
for program, (b) referral criteria, (c) key risk
management concerns, (d) protocol criteria,
and (e) staff qualifications. Through the devel-
opment of clear statements of expected proce-
dures for providing OET, the specialist can
ensure that programs are conducted with the
highest standards of quality and safety. In
addition, while standards of practice for ther-
apeutic recreation (cf. American Therapeutic
Recreation Association, 1993; National Ther-
apeutic Recreation Society, 1995) provide
general guidelines for developing TR interven-
tions,
protocols for OET programs may be best
developed using information related to adven-
ture and experiential programs, such as those
available from the Association for Experiential
Education (Gass, 1998).
Incident Reporting and
Investigation
Another key to maintaining high quality and
safe programming is through the continual mon-
itoring and reporting of incidents that are incon-
sistent with routine practice (Scott, 1994; Vana-
gunas,
1997). Although the most obvious
incident would be a case in which a client, staff
member, or volunteer was injured, other inci-
dents in which actual practices deviate from
standards should also be reported. Given the
inherent risk involved in OET programming,
careful recording of incidents provides the CTRS
with information that can be used to (a) docu-
ment the safety of his/her programs, and/or (b)
provide data to investigate incidents and take
steps to minimize risk of future incidents.
Clinical Privileging
Connolly (1991) stated that clinical privi-
leging must be embraced in order to assure
quality care in therapeutic recreation service.
The process of clinical privileging (usually
conducted on an institutional basis) grants
therapists permission to provide client or pa-
tient care services within well-defined agency
limits,
and is based upon the professional qual-
ifications, competence, and abilities of the
therapist. Similarly, the role of clinical privi-
leging in an OET setting is to create standards
of competence for staff conducting OET pro-
grams. Given the nature of OET programs, the
competency "mix" needed by the specialist to
conduct OET will involve not only the com-
ponents of therapy but also necessitate the
need for various outdoor skills such as emer-
gency procedures, site management, and haz-
ard identification. Although, at present, there
are no universal standards for conducting OET
programs, a variety of training programs are
available through universities and/or private
entities such as Project Adventure, National
Outdoor Leadership School, Outward Bound,
and the Association of Experiential Education.
The inclusion of OET with traditional
health service programs should be integrated
with current facility risk-management plans.
Although such plans should already be in
place for agencies, particularly those conduct-
ing off-facility trips, the inclusion of OET into
programming will require that existing plans
be reviewed and revised. Particular attention
should be paid to policies such as transporta-
tion, evacuation (especially if remote areas are
118
Therapeutic Recreation Journal
used in programming), medications, side ef-
fects from natural environments (e.g., heat and
cold stress, dehydration, and physical exer-
tion),
and first aid in the event of injuries.
Through the use of risk management practices,
OET can be safely integrated into TR pro-
gramming while still maintaining high stan-
dards of client safety.
Issues and Trends in OET
A number of trends and issues that are now
impacting the OET field also have a direct
relationship to TR. A sample of these include
therapist or instructor training and skills, risk
management, the ethical use of risk and danger
in the intervention and application, third party
payment, and demonstrated benefits and out-
comes from participation in OET programs.
Training
The types and level of training therapists/
instructors need in order to be effective is
highly dependent on the specific situation. For
example, how much and what type of outdoor