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Integrating Narrative Family Therapy in an Outdoor Behavioral Healthcare Program: A Case Study

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Abstract

Adolescent mental health is a significant societal concern in the United States. Diagnosable mental health disorders have been reported at rates of 10–20 % among children and adolescents and this does not include adolescents experiencing personal and interpersonal distress not meeting diagnostic criteria. Adolescents who do not respond to traditional mental health services are often placed in residential treatment centers or other out-of-home treatment programs. Outdoor Behavioral Healthcare (OBH) is growing as a viable treatment option for adolescents who struggle with emotional, behavioral or substance related problems; however, questions have been raised about how to integrate the family into an OBH treatment setting. This article describes a case study illustrating how techniques from Narrative Family Therapy can be used to accomplish this integration, and offers a view of using Narrative Family Therapy to further involve families in the treatment and post-treatment process in an OBH program.
ORIGINAL PAPER
Integrating Narrative Family Therapy in an Outdoor Behavioral
Healthcare Program: A Case Study
Steven M. DeMille
1
Marilyn Montgomery
2
Published online: 28 October 2015
Springer Science+Business Media New York 2015
Abstract Adolescent mental health is a significant soci-
etal concern in the United States. Diagnosable mental health
disorders have been reported at rates of 10–20 % among
children and adolescents and this does not include adoles-
cents experiencing personal and interpersonal distress not
meeting diagnostic criteria. Adolescents who do not
respond to traditional mental health services are often
placed in residential treatment centers or other out-of-home
treatment programs. Outdoor Behavioral Healthcare (OBH)
is growing as a viable treatment option for adolescents who
struggle with emotional, behavioral or substance related
problems; however, questions have been raised about how
to integrate the family into an OBH treatment setting. This
article describes a case study illustrating how techniques
from Narrative Family Therapy can be used to accomplish
this integration, and offers a view of using Narrative Family
Therapy to further involve families in the treatment and
post-treatment process in an OBH program.
Keywords Outdoor behavioral healthcare Narrative
family therapy Wilderness therapy Adolescents Case
study
Adolescent mental health is a growing societal concern in
the United States, with diagnosable mental health disorders
reported at rates of 10–20 % among children and
adolescents (Kieling et al. 2011). An even greater number
of adolescents experience personal and interpersonal dis-
tress that does not meet diagnostic criteria (O’Connell et al.
2009). Diagnosable disorders and other interpersonal
problems are concerning as they interfere with the
accomplishment of normal developmental tasks; this
includes developing healthy interpersonal relationships,
social relationships, success in school, and transitioning
into the workforce (O’Connell, Boat, & Warner). If not
addressed, they may lead to adult mental health problems
(Belfer 2008) and chronic health concerns, including pre-
mature mortality (Brown et al. 2009).
Adolescent problems with mental health also negatively
affect the lives of family and friends (O’Connell et al.
2009), not just the adolescent. The impact of a struggling
teen on the family system often drives families to seek
professional help. According to the Substance Abuse and
Mental Health Services Administration (SAMHSA 2012),
approximately 2.9 million youth are receiving professional
services for emotional and behavioral problems. However,
when conventional practices do not work, families often
seek alternative treatment modalities such as out-of-home
treatments. Of those estimated 2.9 million youth who
received services in the last year, nearly 600,000 received
inpatient treatment (hospital, residential treatment, and
foster care), and of these approximately 80,000 received
long-term inpatient treatment (longer than 25 consecutive
days; SAMHSA 2012). Some estimates are even higher,
suggesting that there may be as many as 375,000 youth
treated in residential treatment settings each year (Russell
and Gillis 2010). However, it is unknown how many of
these settings systematically engage in theory-based inno-
vation or program evaluation that advances our under-
standing of effective out-of-home approaches to assist
these troubled adolescents and their families.
&Steven M. DeMille
smdemille@gmail.com
Marilyn Montgomery
marilyn.montgomery@capella.edu
1
RedCliff Ascent, 709 E Main St., Enterprise, UT 84725, USA
2
Capella University, 225 South 6th Street, Minneapolis,
MN 55402, USA
123
Contemp Fam Ther (2016) 38:3–13
DOI 10.1007/s10591-015-9362-6
Several studies support the importance of family
involvement in the treatment of adolescents (Cottrell and
Boston 2002; Diamond et al. 1996; Fauber and Long 1991)
and specifically, adolescents in residential care (Safran
et al. 2009). Hair (2005) reviewed 18 studies and found
evidence that frequent family visits and participation in
family therapy are associated with successful outcomes. In
one study, when an adolescent participated in family
therapy while in residential care, the odds were eight to one
that they would transition to a less restrictive environment.
In contrast, adolescents who experienced parent abandon-
ment were more likely to be discharged to juvenile
detention or a psychiatric hospital (Stage 1998). In addi-
tion, Leichtman et al. (2001) found that family and com-
munity involvement predicted successful maintenance of
gains post psychiatric inpatient treatment. These findings
were corroborated by the National Building Bridges Ini-
tiative (2007), which identified family support as a pre-
dictor of post-treatment success for adolescents in
residential care. In sum, there is a growing body of liter-
ature that indicates family involvement and family therapy
is a significant indicator of post treatment success in resi-
dential care for adolescents.
Outdoor Behavioral Healthcare (OBH) is a promising
alternative option to traditional residential care for strug-
gling adolescents. OBH builds upon an established tradi-
tion of using the wilderness as a therapeutic setting with
unique opportunities for fostering change (Russell and
Hendee 2000). As an out-of-home treatment alternative,
OBH is growing in popularity and at the same time is
accruing evidence of effectiveness (DeMille 2015). In a
survey by Russell et al. (2008), approximately 10,000
youth received services annually in programs that identify
as OBH. As an emerging and contemporary approach,
OBH is receiving attention in the professional literature
and professional conferences (Outdoor Behavioral
Healthcare Research Cooperative; OBHRC 2015), in pro-
fessional magazines (Bray 2014; DeAngelis 2013) and in
the popular media (Telep 2014). While most of the OBH
research has focused on its general effectiveness for
struggling adolescents, some research has been conducted
to explore the integration of aspects of family therapy in
OBH (DeMille and Burdict 2015; Faddis and Bettmann
2010) and to evaluate family change resulting from the
OBH process (Harper and Russell 2008; Harper et al.
2007). Although the ideal role and quantity of family
involvement in OBH treatment is currently unclear in the
literature (Becker 2010), family involvement will likely be
identified as a predictor of post-treatment outcome, as seen
in other studies of family involvement in adolescent
treatment and residential care. To help bridge the research
gap on family involvement in OBH, this paper explores the
integration of Narrative Family Therapy techniques in an
Outdoor Behavioral Healthcare setting and their impact on
one adolescent in treatment and his family.
Outdoor Behavioral Healthcare
Outdoor Behavioral Healthcare, often described as
wilderness therapy, has made significant strides as a pro-
fession in the last decade. In 1996, a small group of pro-
grams formed the Outdoor Behavioral Healthcare Industry
Council (OBHIC; now call the Outdoor Behavioral
Healthcare Council or OBHC) which was intended to
promote program standards and excellence in OBH (OBHC
2015). The council has grown and currently has 22 member
programs. In addition, an Outdoor Behavioral Healthcare
Center was established at the University of New Hampshire
in 2015 with the mission to ‘‘advance the Outdoor
Behavioral Healthcare field through the development of
best practices, effective treatments, and evidenced-based
research’’ (OBHC 2015). The growth of OBH has led to the
development of accreditation standards, managed by the
Association of Experiential Educations (AEE) (AEE 2015).
Although various definitions of OBH and wilderness
therapy have been proposed, the outdoor behavioral
healthcare accreditation manual describes OBH as the ‘‘the
prescriptive use of wilderness experiences by licensed
mental health professionals to meet the therapeutic needs
of clients’’ (Gass et al. 2014, p. 1). Specifically, OHB has
been described as consisting of:
(a) Extended backcountry travel and wilderness liv-
ing experiences long enough to allow for clinical
assessment, establishment of treatment goals, and a
reasonable course of treatment not to exceed the
productive impact of the experience. (b) Active and
direct use of clients’ participation and responsibility
in their therapeutic process. (c) Continuous group-
living and regular formal group therapy sessions to
foster teamwork and social interactions (excluding
solo experiences). (d) Individual therapy sessions,
which may be supported by the inclusion of family
therapy, (e) Adventure experiences utilized to
appropriately enhance treatment by fostering the
development of eustress (i.e., the positive use of
stress) as a beneficial element in the therapeutic
experience. (f) The use of nature in reality as well as
a metaphor within the therapeutic process. (g) A
strong ethic of care and support throughout the
therapeutic experience (Gass et al. 2014, p. 1).
Russell and Hendee (2000) provide a briefer description
of OBH as a therapeutic program or modality that uses
outdoor settings and counseling interventions to assess,
diagnosis, and treat clients. A common feature of OBH
4 Contemp Fam Ther (2016) 38:3–13
123
programs is the immersion of a client in an unfamiliar
environment, where they engage in group living with peers
and guides. Participants also engage in individual and
group therapy overseen by a licensed mental health pro-
fessional and an educational curriculum designed to foster
changes that clients can integrate into their lives upon
returning home.
The outdoors has been used for centuries as a stage for
change and healing (White 2011). In modern times, the
outdoors has been used to foster personal growth, char-
acter development, and to build traits believed to be
necessary for healthy functioning (Cason and Gillis 1994;
White 2011). Walsh and Golins (1976) were some of the
first authors to describe the role of the outdoors in fos-
tering change; asserting that the outdoors provide the
individual with a contrasting environment to see gener-
ality that is often overlooked is a familiar environment. In
other words, the outdoors provides a contrast for an
individual to gain a new perspective on old patterns that
occurred in their familiar environment. Walsh and Golins
argued that this is the first step in helping an individual
reorganize the meaning and direction of their experience.
Additionally, these authors argue that the outdoors is
particularly useful as a contrasting environment because it
is a highly stimulating environment with much to see,
hear and touch, while also providing a sense of uncer-
tainty and risk. At the same time, the outdoors is a neutral
environment. Rules exist in nature that are not arbitrary
and which must be respected—there are no human buffers
to protect individuals from nature, the elements and
consequences that can ensue from taking unwise risk.
Individuals must take on an awareness of their context
and responsibility for their actions in an outdoor setting to
a higher degree than typically required in other settings
(Walsh and Golins 1976).
General effectiveness research on OBH has provided
promising evidence of positive outcomes for struggling
adolescents who receive treatment, indicating that adoles-
cents with emotional, behavioral and substance related
disorders improve during the course of treatment and these
improvements are maintained post discharge (Bettmann
et al. 2012; Clark et al. 2004; Lewis 2013; Magle-Haberek
et al. 2012; Norton 2008,2010a,b; Russell 2003,2005a,b,
2008; Russell and Farnum 2004; Russell and Sibthorp
2004; Tucker et al. 2011,2014; Zelov et al. 2013). Positive
physiological outcomes have also been found (DeMille
et al. 2014). In addition, OBH appears to be effective for a
variety of populations and problems, including adolescents
in the Juvenile Justice system (Jones et al. 2004; Russell
2005a; Wright 1983), adolescent sex offenders (Gillis and
Gass 2010; Lambie et al. 2000), and adolescents with
various diagnosable disorders (Clark et al. 2004; Russell
2006, Russell 2008).
Many residential treatment programs for individuals
claim to improve family functioning, In OBH, the family
has received some research attention which has supported
this claim. In one study, Harper et al. (2007) developed a
questionnaire to measure adolescent and family outcomes
in an OBH program. The 60-item questionnaire contained
five subscales; (a) Family Functioning, (b) Adolescent
Mental Health, (c) Adolescent Behavior, (d) School Suc-
cess, and (e) Positive Social Relations. These authors found
numerous improvements in family functioning at 2 months
post discharge, with the exception of family arguments
which increased at 2-month post treatment. Another study
by Harper and Russell (2008) also found a positive trend
toward improvements in family functions post OBH
treatment. The authors noted that families reported a sta-
bilizing effect and a generally rewarding experience from
the wilderness treatment process.
Narrative Family Therapy
Narrative approaches to therapy have grown in popularity,
particularly in the field of family therapy (Carr 1998). This
is in large part due to the efforts of Michael White and
David Epston (Epston and White 1992; White 1989), who
describe their approach to therapy as based on principles
rather than methods. Narrative therapy grew out of the
postmodern perspective, which is reflected in its principles:
(a) there is not one universal reality but reality is socially
constructed; (b) language constructs reality; (c) reality is
maintained through narratives; and (d) not all narratives are
equal (Freedman and Combs 1996). From those founda-
tions, narrative family therapy views human problems as
arising and being maintained by oppressive stories that
dominate a person’s life. Problems occur when individual
stories do not fit with their lived experience. According to
the narrative perspective, treatment is a process of re-au-
thoring personal narratives by providing a new and dif-
ferent perspective on a problem-saturated narrative. Re-
authoring a narrative is done through a process of helping
the client (a) externalize the problem(s) they are experi-
encing, (b) deconstructing problem-saturated narratives
through questioning, (c) identifying unique outcomes or
times when a person was not oppressed by their problem,
(d) link unique outcomes to future and provide an alter-
native and preferred narrative, (e) Invite members of a
person’s social network to witness the new narrative,
(f) document new knowledge (Carr 1998; O’Connor et al.
1997).
Because postmodern perspectives place emphasis on
principles rather than techniques, formal techniques are
limited in narrative therapy. However, some authors have
identified practices that are useful in assisting a person in
Contemp Fam Ther (2016) 38:3–13 5
123
re-authoring a personal story such as the ‘‘telling and re-
telling of story,’’ letter writing, and documentation (Carr
1998). For example, letter writing has been used in indi-
vidual, family and group therapy to address a variety of
issues including improving family communication, trauma,
grief and loss, identity development, and crisis manage-
ment (Riordan 1996; Tubman et al. 2001).
Narrative therapy has been used extensively in outpa-
tient settings, but it has also been used in inpatient settings,
including OBH. For example, Faddis and Bettmann (2010)
describe the use of reflection teams in an OBH setting.
Reflection teams were heavily influenced by Milan’s
therapeutic approach (O’Connor et al. 2004) and have been
adapted and incorporated into the narrative therapy
approach. The authors describe a process of using field
staff and other families as part of a reflection team. The
reflection team observes the session and at the end is asked
specific questions based on their observations of the
session.
Narrative Family Therapy in an Outdoor
Behavioral Healthcare Setting
Narrative family therapy provides some structural and
theoretical advantages that can be useful in an Outdoor
Behavioral Healthcare setting. As noted above, OBH
consists of ‘‘extended backcountry travel and wilderness
living experiences long enough to allow for clinical
assessment, establishment of treatment goals, and a rea-
sonable course of treatment’’ (Gass et al. 2014, p.1).
Immersion in the backcountry and wilderness living brings
many logistical challenges for families who wish to be
actively involved in the treatment process. First, wilderness
programs are often located in rural and difficult to access
locations. Thus, significant travel is required for most
adolescents and families in order to participant in OBH.
Second, the time and money required for travel limits a
family’s ability to physically participant in family therapy.
Attempts are often made by programs to have individuals
involved in the therapy process through family visits and
therapy sessions; however, these visits tend to be limited
during the treatment process because of financial and time
constraints. Third, the backcountry environment limits the
potential for electronic communication between the ado-
lescent and family. Therefore, communication between a
family and adolescent in an OBH program often occurs
through letter writing.
As a result of the limitations to conducting family
therapy in an OBH setting, creative approaches to imple-
menting family therapy are needed. Narrative family
therapy provides potential advantages that compensate for
some of these limitations. Narrative therapists often work
alone with a client, or flexibly, as Harlene Anderson
described, ‘‘with individuals, parts of families, and mem-
bers of the larger system’’ (1997, pp. 66–67). Freedman
and Combs (1996) noted that they prefer to ‘‘interact with
one person in the family while the others listen’’ (p. 187).
This process makes family members an audience to each
other and their personal narratives. The telling and retelling
of the story occurs with the family as an audience to the
story. This approach is useful in an OBH setting, as
adaptation can be made to tell and retell the narratives
through writing, a common feature of OBH programs.
Family members who are distant can still be involved in the
process through being asked to reflect on stories that are
being told (Freedman and Combs 1996).
There have been criticisms made against this ‘‘distance’
approach to family therapy. For example, the lack of
observation of interpersonal patterns among the family
members has been criticized (Minuchin 1998). However,
the use of letter writing as a ways for families to tell, retell,
and reflect on stories has great potential as a means of
integrating the family during the entire treatment, even
when the adolescent is in the backcountry. The following
case study illustrates the application of Narrative Family
Therapy techniques in an OBH setting.
Case Study
The case study method is useful in documenting, evaluat-
ing and disseminating new approaches or the new appli-
cations of an approach (McLeod 2010). Case studies
provide an in-depth understanding of a new or innovative
approach and have a long history of use in the field of
psychology and medicine (Creswell 2007). In this case
study, the Narrative Family Therapy treatment of an ado-
lescent male with severe intrapersonal and interpersonal
issues will be described, with a focus on the application
and outcome of the family therapy. OBH is a dynamic
treatment modality that includes individual, group, and
family therapy combined with the prescriptive use of the
outdoors and wilderness living, all occurring within small
peer group dynamic. Thus, the overall treatment integrates
many techniques and modalities. Greater detail on the
different components of treatment such as the individual,
group, wilderness-living and backcountry travel can be
found in DeMille and Burdick (2015). This case study will
highlight the implementation of narrative techniques as a
key aspect of the family therapy.
The Program
The OBH program used in this case study is located in the
Western United States. Adolescents who are receiving
6 Contemp Fam Ther (2016) 38:3–13
123
treatment are referred to as ‘‘students’’ while they are in the
program; academic credits are earned through completing
the education/experiential curriculum. Students also
receive weekly individual and group therapy while in
treatment. Parents meet with the therapist weekly via
conference call. The program uses a continuous flow
expedition model (Russell 2003), which entails students
being immersed in wilderness living and backcountry tra-
vel during their entire stay. The backcountry travel entails
hiking/backpacking. On average, participants participate in
hiking/backpacking expeditions four to five times a week
for three to five miles each trek. The wilderness living
involves setting up and breaking down a campsite using
low-impact camping principles (Marion and Reid 2007). In
addition, students learn wilderness skills practical for their
living situations. For example, students learn primitive fire
making for warmth and preparing meals.
Adolescents are referred to this OBH program for var-
ious emotional, behavioral, relational, and substance rela-
ted problems. The program reports that families they work
with have ‘‘exhausted emotional, familial and community
resources’’ (Who Do We Serve?, 2015, p. 7). The overall
treatment goal is to disrupt dysfunctional relational and
behavioral patterns that are impeding healthy adolescent
development and restore clients’ age-appropriate func-
tioning. The dysfunction that is impeding healthy adoles-
cent development may come from mental health disorders,
trauma, interpersonal problems at home or in the commu-
nity, and/or substance use. Treatment goals are achieved by
integrating evidenced based therapies with clinical exper-
tise in the context of patient characteristics, culture, and
preferences (Anderson 2006). In addition, goals are
achieved through the use of wilderness living, interpersonal
relationships, an experiential curriculum, and a healthy
lifestyle (healthy diet, sleep habits, work and exercise).
Family involvement in the treatment process occurs
through different methods, both in person and at a distance.
Families (parents or legal guardians) participate in an ‘‘end
of trails’’ ceremony with their child as part of the treatment
process. The ‘‘end of trails’’ ceremony involves the parents
visiting their child in the outdoor environment and camping
with their child. Parents are involved in a series of group
and family therapy sessions, with their child and without
them. In addition to the in-person involvement, families
also participate in family therapy through a series of nar-
rative writing assignments that the student and family
complete when the student is in the backcountry and are
unable to attend. The narratives are designed to be a way
for the adolescent and the family to tell and retell their
story, to identify problem-saturated stories, and to look for
unique outcomes. Sharing and reflection are also built in
through exchanging narratives. Students are asked to share
their narrative with their peers in group therapy. Parent
narratives are shared with the student in therapy, where
they are given an opportunity to reflect on their parents’
narratives. Following is a description of the implementa-
tion of narrative family therapy with one case in an OBH
program.
History and Reason for Treatment
Sam is a 16-year-old male who was referred by his parents
for treatment in an OBH program in the Western United
States. Parents reported that they sought treatment because
of Sam’s emotional dysregulation, poor family relation-
ships, and academic problems. Parents described Sam had
been ‘‘out-of-control’’ within the home. He was refusing to
go to school, refusing to attend local counseling sessions,
and refusing to socialize outside of playing interactive
video games online. His parents reported that whenever
they would attempt to place restrictions or boundaries on
his behaviors, Sam would become emotionally volatile and
make threats to hurt himself. They also reported that Sam
stop talking with his family, was ignoring everyone in his
home, and had refused to engage in outside activities
(sports, school, travel, work).
Sam’s parents reported that in the past they believed
they had a close relationship with their son. They described
Sam as being intelligent and academically gifted, athletic,
and talented both intellectually and physically. In the past
Sam was treated for depression; however, his parents noted
it was never very successful. He was also previously in
treatment for family problems that emerged around his use
of video games, primarily, conflicts that arose when his
parents would put limitations on his gaming. During the
last 2 months before entering treatment, Sam had refused
to leave the couch, even to bathe. This was reportedly in
response to having restrictions placed on his gaming
console.
Assessment and Therapeutic Goals
When Sam arrived for treatment at the OBH program, his
parents identified three goals for their son. First, they
wanted him to reengage socially. They wanted him to leave
the house, spend time with friends, attend school again, and
to start making progress towards independence and adult-
hood. Second, the parents wanted to improve the family
relationships, which had become hostile and dysfunctional
for all family members. Finally, they wanted to see more
interpersonal flexibility from Sam. They noted that when
Sam would set his mind on something he would not back
down until he got what he wanted.
When Sam was asked what he wanted to work on in
treatment he stated ‘‘I want to teach my parents they cannot
control me.’’ Sam denied any other treatment needs or past
Contemp Fam Ther (2016) 38:3–13 7
123
need for treatment. Sam also noted that he was not ‘‘de-
pressed’’ or ‘‘addicted’’ to games and it upset him when
people would insist otherwise. Sam acknowledged that his
relationship with his family was poor and that he had lost
most his friends.
In response to Sam’s adverse reaction to the use of
diagnostic labels, a functional approach was taken in Sam’s
treatment planning. This was done by focusing on func-
tional goals and not the treatment of symptoms associated
with diagnoses. The first goal with Sam was to help him
actively engage in the treatment process and during the
fourth session, Sam collaboratively developed the follow-
ing goals. The first goal was to engage in appropriate
behaviors with peers and authority figures. This included
meeting basic expectations, following directives, and being
a positive influence on others in his peer group. The second
goal was to improve family relationships. This goal
included two parts: Sam would start communicating with
his parents through letter writing, and he would send and
receive narratives with his parents, addressing the problems
that he perceived in their relationship.
Narrative Family Therapy
Initially, Sam did not want to engage in therapy or any
form of reflective process. As a result, the first three ther-
apy sessions focused on developing a working relationship
and helping Sam feel safe. In addition, the first sessions
focused on helping Sam develop hope that his life could be
different and hope that his relationships could improve.
This was a major issue for Sam as he did not believe he or
his family could change anything. He felt stuck. Finally,
therapy also focused on assisting Sam with adapting to his
new contrasting outdoor environment. During the first three
sessions Sam was encouraged to reflect on his old envi-
ronment, relationships, and choices. At first Sam was rigid
and did not want to look at his environment, relationship
and choices. However, as Sam spent time in the outdoors
and had opportunities to contrast his old familiar environ-
ment with his new unfamiliar environment, he began to
identify aspects of his life that he did not want to maintain
going forward with his life.
In the fourth therapy session Sam acknowledged his new
perspective; stating that he wanted to ‘‘try something dif-
ferent.’’ He noted that he was not happy with his current
situation and current relationships. During that session,
Sam set goals for himself and became more open to share
his story. Family therapy began with Sam by creating a
safe therapeutic environment where he shared about his
struggles prior to being placed in treatment in an OBH
program. While Narrative Therapy posits the necessity of
creating a collaborative or egalitarian relationship between
therapist and client, a therapist in this OBH program has an
evaluative and gate-keeping role with the student that
makes an egalitarian relationship in therapy unrealistic.
The therapist is the gate-keeper of the decision about when
the student is ready to transition to a less restrictive treat-
ment environment, and students are aware of this dynamic.
Thus, initially in therapy, the goal is to minimize the
impact of that dynamic on the treatment process and to
create a safe therapeutic environment.
In the fourth session, Sam provided the ‘‘thin descrip-
tion’’ of his problem. Sam identified the different areas of
his life where the dominant story was imposed upon him.
However, Sam described that his problems were not due to
his acceptance of the dominate story but from his resistance
to accepting the dominate story. Sam discussed his issues
with being described as ‘‘depressed’’ and ‘‘addicted.’’ Sam
insisted that is not ‘‘who he is.’’ Sam also mentioned a
professional who labeled him with ‘‘Aspergers’’ and how
he never wanted to return to that professional. In addition,
Sam indentified his struggles with being identified as
‘smart’’ and being pressured to attend a prestigious
boarding school where he received a scholarship. Through
the use of ‘‘how’’ and ‘‘when’’ questions Sam was chal-
lenged in the session to explore in more depth the struggles
he was experiencing.
At the end of the session, Sam was challenged to con-
tinue to ‘‘tell his story’’ and ‘‘re-tell his story.’’ He was
given a few open ended questions to reflect on and respond
to before the next therapy session. This process would
continue throughout Sam’s entire stay and his answers in
the assignments were labeled as Sam’s autobiography. The
reflection questions Sam was given after the fourth session
related to his home, family, authority, and significant
events of childhood. Some of the questions included ‘‘what
did your home look like as a child?’’ ‘‘What did it take to
live in your home?’’ ‘‘Who was in charge in your home and
what did it take to be in charge?’ ‘What were the most
fearful events in your childhood?’’ In addition, Sam’s
parents were given open-ended reflection questions similar
to Sam’s; their answers were called the parent narratives.
Those questions included ‘‘What did you child’s home look
like?’’ ‘‘What were the roles and expectations of each
family member and how were they communicated?’’
‘What were the most significant events that defined the
family?’
In the fifth therapy session, Sam shared his autobiog-
raphy and the parent narrative was read to Sam. Some of
the themes that came out of the parent narrative included
an emphasis that the children in the family were expected
to ‘‘do the best their abilities enabled them to,’’ and to ‘‘be
polite and respectful.’’ Furthermore, the narrative stated
‘we tried to communicate this primarily by example,
although we’re far from perfect.’’ Some of the significant
events that were identified in the parent narrative included
8 Contemp Fam Ther (2016) 38:3–13
123
significant loss, great academic success in school, and
Sam’s being bullied in school. Sam was asked to reflect on
what he read and heard from his parents. He was asked
‘How was it to read your story and then hear your parents’
story?’’ ‘‘What stood out to you?’’ and ‘‘Was their anything
that surprised you?’’ These questions were intended to
produce a ‘‘thick description’’ or ‘‘thickening’’ of Sam’s
story by allowing him the space to make interpretations.
Sam was asked to identify situations from his parents’
narrative that were surprising or that did not fit into his
problem-saturated narrative. A few parts of the narrative
stood out to Sam. Sam noted that he felt much pressure to
be successful because of his physical and academic
capacities. His parents did expect him to do ‘‘the best his
abilities enabled him,’’ and Sam stated how hard that was
for him. Sam also noted that he always felt like the problem
in the family and he was surprised to hear his parents say,
‘‘ although we’re far from perfect.’’ Sam also responded
to the bullying by saying that he did not think it was as
significant of an event as his parents did. Some of the
unique outcomes, such as the identified patient story Sam
had for himself, were used to begin to reconstruct an
alternative story.
At the end of the session, Sam was challenged to con-
tinue to ‘‘tell his story’’ and ‘‘re-tell his story’’ and was
given new open-ended questions to reflect on before the
next therapy session. The questions that Sam was given
focused on discipline and self-discipline, such as ‘‘Who
was in charge of the discipline in your home?’’ ‘‘How was
discipline administered and how did you respond to the
discipline?’’ ‘‘What areas in your life have you shown self-
discipline and what areas are out-of-control?’’ ‘‘How do
others know that you are self-disciplined?’’ Sam’s family
was also given open-ended reflection questions similar to
Sam’s. They included ‘‘From where did you derive the
method of discipline you implemented in your home?’’
‘Was this different from the kind of discipline you
encountered as a child? How so?’’ ‘‘How did your child
respond to the discipline you provided?’’ ‘‘What seemed to
be successful?’’ ‘‘What would you have changed and
why?’’ ‘‘When were you most encouraged by the actions of
your child?’’ Finally, at the conclusion of the fifth session,
Sam was challenged to share his autobiography with his
peer group. The peer group would become the witness to
the thickening description and the alternative story. This
was done to increase the probability that the alternative
story will take root for Sam outside the therapy session and
later outside the OBH program.
In the sixth session, Sam shared his autobiographies and
his parents’ new narrative was read to him. After
exchanging writings, Sam was asked similar questions to
help produce a thick description of the story. Sam noted in
this narrative his parents seemed the most pleased with him
when he was interacting and playing with his siblings and
not when he was achieving or accomplishing. Sam’s par-
ents stated ‘‘we are most encouraged by Sam when he was
caring with his sisters, honest with us and everyone else,
when he showed love to us and to his sisters.’’ Sam noted
that he liked the high relational focus of the narratives and
not the focus on achievement. The shared beliefs that Sam
experienced through telling and retelling his story and
hearing his family story started to highlight shared values
and beliefs within the family.
At the conclusion of the session, Sam was challenged to
continue to ‘‘tell his story’’ and ‘‘re-tell his story’’ and was
given new open-ended questions to reflect on and respond
to before the next therapy session. Sam’s family was also
given new open-ended questions similar to Sam’s to reflect
on and answer. Again, Sam was challenged to share his
autobiography with his peer group, who witnessed the
thickening description and the alternative story. The pro-
cess of exchanging narratives occurred eight times during
the course of treatment while Sam was in the backcountry
of an OBH program. Each situation was followed by the
group witnessing the process through the sharing autobi-
ographies with the peer group.
Concluding Therapy and Follow-up
The family narratives concluded with an incorporation
practice. On Sam’s last day of treatment in the OBH pro-
gram, Sam shared his alternative story with his family. The
alternative story incorporated what he had experienced in
the outdoor program, with his peer group and throughout
the narrative therapy process. After Sam shared his narra-
tive, Sam’s parents were asked to reflect on what they
heard and experienced. Parallel experiences were identified
and used as bridges for Sam’s parents to become a resource
for Sam going forward instead of part of the problem.
In an exit interview Sam reported the most valuable
thing he had taken from his time in the outdoors was how it
‘helped improve my family relationship.’’ This improve-
ment was apparently sustained. One year after Sam had
completed treatment he and his family responded to a
questionnaire about their experience. Sam noted in his
questionnaire:
I think the most important part of [Program Name] to
me was the space that I found there. I was in the most
remote place I had ever been and I didn’t feel like I
had to be anything. Whereas before I was just who-
ever my parents thought I was, atI began to
become who I am. I don’t think that I could have
learnt to be myself had I been at home. I think that
learning to sit with myself and being okay with who I
am is something that started for me out there.
Contemp Fam Ther (2016) 38:3–13 9
123
Sam also noted in the questionnaire about the impact of
having his group as a witness:
The first time I told my group as a whole my life story
I cried a hell of a lot because it was the first time that
I had told anyone my age about what was going on
back home. My friends were extremely helpful and
respectful of me, and that experience helped me a lot
for a while to feel comfortable with people.
In addition to feedback from Sam, his parents were asked
to reflect on their treatment experience in an OBH
program. Sam’s parents reported:
[Program] helped us understand [Sam], his concerns,
his fears, and his needs. We could not have done this
while he was at home as he was unwilling to com-
municate with us. Removing him from the house for a
few weeks gave everyone involved the chance to
rethink what was going on and it helped us all get a
bit of perspective on the issues [Sam] was dealing
with.
The parents continued:
[Program] made us think about our relationship with
our son, and how our role might have had an influ-
ence in [Sam’s] lack of development. [Program] did
this without blaming us and without resentment. Our
changes as parents somehow came to us from inside
ourselves; [Program] helped us become a better ver-
sion of ourselves as parents without us noticing,
without blame, and without resentment.
Sam’s parents were also asked what aspects of the
treatment process was the most helpful.
For us parents, narratives were very helpful in two
ways. Firstly it helped us rethink about our relation-
ship with our son, and about how our role might have
had an influence on [Sam’s] development. Writing
the narratives had a huge impact on our way of par-
enting our kids. Secondly, the parents’ narratives
made us get involved in [Sam’s] improvement, it
allowed us play a part in his progress even though he
was miles away from home. It was a way of staying
in touch with [Sam] while he was staying in the
wilderness, a way of working together with him even
though we were miles away from him.
Suggestions for Family Therapists
The benefits of family involvement in therapy (Cottrell and
Boston 2002; Diamond et al. 1996; Fauber and Long 1991)
and in residential care (Hair 2005; SafranGass et al. 2009)
have been well documented. Narrative Family Therapy
provides methods for family therapists to integrate family
involvement when there are limited opportunities for con-
joint sessions. Here, we offer suggestions for family ther-
apists interested in applying these techniques to increase
family involvement in OBH or other out-of-home
treatments.
First, the therapist must be aware of the nature of their
relationship with the client in treatment. In OBH and res-
idential care there is often an evaluative and gate keeping
role that the therapist must maintain. This power differ-
ential makes it impossible to create a truly egalitarian
relationship and the therapist must acknowledge this
dynamic. Nevertheless, the therapist should attempt to
create a safe environment for the client to discuss difficult
family dynamics. Working within a narrative framework
supports therapists in taking an authentically inviting
stance, despite the evaluative role. O’Connor et al. (1997)
found that clients valued the therapists who used the nar-
rative approach because the therapists appeared to respect
their perceptions and experiences. In addition, the non-
punitive physical distance that OBH provides offers some
safety for the clients to feel open to discussing problems
and challenges without the fear of what happens after the
session, as well as the freedom to imagine and create a new
narrative. Sam noted in his feedback at 1 year that ‘‘I was
in the most remote place I had ever been and I didn’t feel
like I had to be anything. Whereas before I was just
whoever my parents thought I was, at [Program] I began to
become who I am.’’ The physical distance can create a
sense of safety for describing family problems, while the
outdoor setting provides fresh standpoints for taking new
perspectives and creating new narratives.
Family therapists can use the contrasting outdoor envi-
ronment to encourage willingness to reflect and find new
perspectives that challenge old dominant stories. In the
case of Sam, family therapy was not pushed. When Sam
acknowledged that he wanted to ‘‘try something different,’
this came after he had spent time in the outdoor environ-
ment. The outdoor environment gave Sam a neutral and
stimulating environment to reflect on his dominant story
and eventually led him to look for new perspectives and
alternative stories. The outdoor environment enhances
family therapists’ invitations for clients to create new
perspectives.
The narrative approach works with the individual parts
of the system and with others as an audience to the stories
being told in therapy. For family therapists working in
OBH, this method of family involvement is very conducive
to the treatment setting. The telling of stories and being an
audience for stories are practices that can be delivered in an
asynchronous format through letters or structured writing
assignments. The asynchronous format provides an
10 Contemp Fam Ther (2016) 38:3–13
123
opportunity for the family therapist to discuss reactions to
the stories separately with families and adolescents, which
may increase a sense of safety and allow the client to more
fully develop their ‘‘voice,’’ and then to share their
reflections with each other through writing.
Finally, it is important to note the use of the group as a
witness of the alternative story. An advantage of writing
the stories is the potential for the stories to be shared and
thickened by having a peer group witness the story and
then be a witness to the development of the alternative
story. Witnessing supports the development of the story,
and fosters internalization of the alternative story and
generalization of the story to new settings such as home
environments reentered after treatment.
Conclusion
One of the greatest struggles of out-of-home treatments is
the involvement of families in the treatment process. The
Narrative Family Therapy techniques described here
illustrated how families can be involved in the therapy
process, even at a distance. In the case of Sam, a struggling
adolescent placed in an OBH program, techniques from
Narrative Family Therapy were used to meet the thera-
peutic goal of improving the family relationship. Specifi-
cally, the process of deconstructing the dominant story and
reconstructing an alternative story was facilitated by the
contrasting outdoor environment offered in an OBH treat-
ment setting. The narrative family therapy integrated into
his treatment included techniques of collaboration, identi-
fying unique outcomes, thickening the story, inviting out-
siders to witness, and incorporation practices with families.
The case illustrates several techniques family therapists can
use to further involve families in inpatient treatment pro-
grams, particularly OBH programs for struggling teens.
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... Primary child and youth participants ranged from six to eighteen years of age. Only two studies reported on the referral agent, which in both cases were the parents [29,30]. In one study [31], the use of coercion due to involuntary treatment was reported. ...
... Juvenile status offenders. The study by DeMille and Montgomery [30] provided information about a single clinical case, but they did not describe the methodology used to collect and analyze data. All other studies presented in this review (n = 6) used a quantitative approach, in which most of them included tests or instruments that have shown to provide valid and reliable results (n = 5). ...
... Six of the family-based outdoor programs described varied in length from three days to three months, whereas no information about the length of the program was provided by DeMille and Montgomery [30]. ...
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Outdoor therapy and family-based therapy are suggested to be promising interventions for the treatment of mental health problems. The aim of the present scoping review was to systematically map the concept, content, and outcome of combining family- and outdoor-based therapy for children and adolescents with mental health problems. The Joanna Briggs Institute methodology and PRISMA guidelines were applied. Eligible qualitative and quantitative studies were screened, included, and extracted for data. Seven studies were included. Findings from these studies indicated that family-based outdoor therapy programs have a positive impact on family- and peer relationships, adolescent behavior, mental health, self-perceptions (self-concept), school success, social engagement, and delinquency rates. However, participant characteristics, study design, and content and mode of delivery of the interventions varied substantially, hence preventing detailed comparison of outcomes across studies. In addition, most of the studies included few participants and lacked population diversity and comparable control groups. Although important ethical concerns were raised, such as non-voluntary participation in some of the programs, there was a lack of reporting on safety. This review indicates that a combination of family- and outdoor-based therapy may benefit mental health among children and adolescents, but due to the limited number of studies eligible for inclusion and high levels of heterogeneity, it was difficult to draw firm conclusions. Thus, future theory-based studies using robust designs are warranted.
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... OBH integrates psychological assessment and traditional psychotherapy models such as Adlerian theory (DeMille & Burdick, 2015), cognitive and behavioral therapies (Berman & Davis-Berman, 2008), psychodynamic therapy (Norton, 2010b), and Narrative Family Therapy (DeMille & Montgomery, 2016) in an outdoor treatment environment. Walsh and Golins (1976) were some of the first to describe the role of the outdoor environment in fostering change, asserting that the outdoors provides individuals with a contrasting environment to observe aspects of themselves often overlooked in a familiar environment. ...
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