Defining A Safe Wilderness School, Therapy And
Michael Conner, Psy.D
Mentor Research Institute:
May 31, 2013
Managed health care in this country has become big business. As a
direct consequence, the relationship between consumers and health care providers has been
increasingly eroded by dangerous cost control practices, restrictions of care, treatments
based on business decisions rather than professional decisions, and finally, by managed
cares creation of incentive systems where medical and mental health service
providers make more money by providing less care. The services covered by insurance or
provided by HMOs for "youth at risk" have been increasingly restricted and
eliminated over the past decade. As a consequence of managed health care policies, many
behavioral and social problems that children experience are being medicated rather than
effectively managed or treated. Managed care companies focus on short term
effectiveness" and assert that psychotherapy, family therapy, or intensive and
non-traditional treatment resources such as wilderness programs are not
effective or not proven effective. The use
of sedating antipsychotics, powerful stimulants and sedating antidepressants are
increasing in America to restrain and "manage" rather than help children who are
suffering and showing outward signs of confusion, anger and emotional turmoil.
Parents searching for alternatives to medicating their children for
social and behavioral problems are turning to wilderness schools and intervention programs
when "office" therapy, residential treatment, psychiatric hospitals and criminal
justice programs fail. Out of desperation and hope, parents are turning to wilderness
programs to help change the lives of their children for the better. Mental health
professionals who are frustrated with inadequate change by traditional treatment programs
such as residential care are exploring the wilderness therapy option. Wilderness schools
are demonstrating preliminary effectiveness rates in the range of 60 to 90% in comparison
to traditional treatment program in these populations that produces rates at approximately
40 to 50%. Of course the difficulty of the populations these schools work have a
significant impact on outcomes rates as does the quality and effectiveness of the program.
The importance of "Defining A Safe Wilderness Intervention
Program" is clear. Outdoor Schools and wilderness interventions are powerful
psychological, emotional and physical interventions. More important, wilderness schools
are largely unregulated in the United States and many of the people operating these
schools, as well as the paraprofessionals providing services, are unlicensed and have
little or no relevant training. Paraprofessionals providing most of the direct contact
with children, including counseling, often have minimal or no training in medicine, crisis
intervention, counseling, psychology or behavioral science - although some have extensive
experience working in wilderness schools. Supervision and services within wilderness
therapy schools are usually provided by paraprofessionals. A few programs have state
regulation, but this by no means provides the level of information or assurance that
referring professionals and parents need to decide whether or not a child will benefit or
thrive from a program. State regulations in many states are antiquated, irrelevant
and bureaucratic nightmares for programs and can in some cases the
regulations directly interfere with the needs of students and drive cost
to unreasonable levels.
In contrast, the role and influence of professionally trained
counselors, psychotherapists, physicians and psychologists will vary in these programs.
Internal monitoring, supervision and oversight of wilderness programs by professionals
vary considerably from state to state and from program to program. External monitoring of
wilderness and traditional treatment programs are usually minimal and primarily activated
by complaints or scheduled administrative reviews by state or county agencies. Often there
is no regulation or review. In regulated treatment settings professionals provide
oversight and supervision and have direct responsibility for the behavior of
paraprofessionals. In many wilderness treatment programs, professional oversight and
supervision is often minimal.
A familys decision to enroll their child in a wilderness
therapy and intervention program is personal and important. There are many programs to
choose among and the choice must be well informed. It may be a blessing that managed
health care and insurance companies generally do not cover wilderness treatment services,
and when they do provide coverage, the financial reimbursement is small compared to
the overall cost. And, because managed health care does not offer these services to
families and youth at risk, they cannot control how wilderness programs are designed, and
then restrict what services and the level of services offered. Parents can
still "shop" for services that address their childs needs and choose the
intensity, design and values that guide the childs wilderness treatment experience.
On the continuum of education and mental health care, Wilderness Programs and Outdoor
Schools are innovative, intensive and have tremendous benefits to a child's psychological
and emotional growth. The lasting positive benefits can be as little as 3 to 6 months and
as long as a lifetime..
This article is one of a series of papers intended to help families,
educational consultants and mental health professionals recognize and begin to understand
the problems and potential consequences inherent in wilderness schools, therapy and
intervention programs. Students enrolled in wilderness programs face the possibility of
serious physical and psychological injury, or loss of life, when risk factors are denied,
misunderstood, not recognized, ignored, or not addressed. Wilderness Programs and Outdoor
Schools are no more dangerous than any therapeutic boarding school or residential
treatment based program. All programs, schools and summer camps that work with children
have some degree of risk. Many public schools may have an even greater
level of risk in that
student carry weapons on campus and the level of supervision can range from minimal to none.
This article is based on a review of the operations of four
distinctly different structures in outdoor and wilderness therapeutic programs and on
confidential interviews with employees, former employees, graduates and parents of
graduates from those programs. Three programs had 30, 60 and 90 days approximate fixed
lengths of treatment designs. Two additional programs were designed as an "open
ended" programs with a single flat fee regardless of the duration in the program.
This article is intended to help readers to understand what could be
considered critical risk and decision factors when selecting a wilderness program. At
present, the programs with which I have had contact and many other wilderness treatment
companies are struggling to understand and address the concerns identified here. This
paper has been written to promote discussion between parents, consumers, professionals,
paraprofessionals and the owners of wilderness programs. No statement contained here is
intended to explicitly or implicitly imply that any single program is dangerous or unsafe.
Usually there are numerous factors to consider that can mitigate or minimize an otherwise
high risk or potentially dangerous situations. Again, the goal of this review is to foster
awareness and to create discussion.
An effective drug and alcohol screening program for all
Drug abuse is unfortunately common in the United States today. Drug
affected employees are dangerous in outdoor or wilderness programs. As many as half of the
people who apply for jobs in wilderness and outdoor programs use both marijuana and
alcohol. Random and frequent drug screening is essential. Employees should be drug tested
an average of 3 times a month during their first 3 months of employment. Continued random
testing can assure compliance with responsible program standards.. Testing by a clinically
competent laboratory is essential. A competent laboratory can detect whether a clinical
sample has been altered or the testing subject has ingested a substance that would alter a
body fluid sample. People using illegal drugs are not appropriate to work with youth at
risk. Costs for drug screening are minimal when compared to the risks with drug involved
A complete reference and criminal background screening of
Up to 5% of the people who apply for entry level positions as field
staff are wanted by the police or have criminal backgrounds that involve destructive,
violent or other serious criminal behavior. Routine and thorough background checks are the
best way to reduce the risk that students might be abused or influenced by sociopathic and
inappropriate values. A routine screening procedure is the best deterrent. Finger print
and background investigation using law enforcement data bases are essential. The cost per
background check is minimal.
A written policy and procedure that proscribes inappropriate and
abusive practices by employees.
Parents and professionals referring to wilderness and outdoor
programs should ask for a summary of program policies and procedures that describe
appropriate as well as inappropriate and unacceptable behavior by staff. Program
descriptions of inappropriate or illegal behavior should include:
Physical abuse is prohibited. This would include striking or
pushing students, denial of basic comforts such as warmth, movement, reasonable access to
hygiene or timely elimination.
Emotional abuse or neglect is prohibited. Demeaning and
derogatory language including yelling at students to "break them down" or to
gain control and compliance can be very damaging.
Inappropriate or excessive use of force or restraint is prohibited. There
are numerous programs and certification procedures by which trained staff can achieve
control and compliance when students become dangerous or destructive. Use of pain
compliance or inappropriate hold techniques must be strictly avoided. Training is
Inappropriate or unwarranted isolation, restraint or long term
restraint of a student is prohibited. Such procedures are high risk procedures.
Students reactions can be extreme and lead to decompensation. The ability to
restrict movements is not high in a wilderness setting and physical restraints can lead to
Sexualized behavior, sexual relations with students and sexual abuse
is prohibited. Such behavior is illegal in most circumstances and highly damaging in
Deprivation of food and water is prohibited. Under no
circumstances should students be denied necessary nutrients as punishment. Students should
have access to healthy diets with adequate calories including nutritional supplements.
Deprivation of emotional, social and other psychological needs is
prohibited. Such consequences or punishments are extremely controversial and would
almost never be appropriate in an outdoor setting. The risks associated with subsequent
behavior are high.
Denial of medical care or attention is prohibited. This more than
any issue is critical to the health and safety of students. Prior to admission, many
students have lived stressful and often self-harming lives. Sexual activity, drug use and
poor health habits are such that some students may require treatment for problems ranging
from bronchitis, to pneumonia, pelvic inflammatory disease, venereal disease, and ear or
Forcing students to eat or take fluids is prohibited. Students
will often lose their appetites or refuse food in protest when they enter a program. Such
behavior is often oppositional defiance of program requirements. Health risks of refusing
food are usually extremely low. Force feeding a student is not only unnecessary but
Restriction or denial of necessary communication with family and
other designated responsible persons is prohibited. Mail and the right to communicate
is essential for parents to keep in touch with their child and to monitor the childs
progress. Mail is for practical purposes the best way to maintain communication.
A policy that outlines appropriate response to routine, urgent
and emergency mental health or medical problems.
Serious or life threatening medical and mental health injuries and
problems in outdoor treatment programs are not usually the result of
"accidents". In most situations, "accidents" are the result of
avoidable errors, negligence or incompetence. In nearly all situations there are numerous
warning signs which can prompt action in a responsive or timely manner. Awareness of
safety issues and training staff to think proactively in terms of "What if?" is
the best deterrent. In addition to the ability to think in terms of "what if?",
a safe program will have a clear and documented understanding of appropriate and essential
responses by field staff and program management. A safety and risk management policy and
procedure is a necessary part of any program. Safety and risk management involves the
proactive assessment of near accidents and accidents with follow-up training and awareness
enhancement of staff. Conscientious and responsible behavior on the part of staff must be
supported and maintained through hiring practices, monitoring program activities, staff
supervision as well as routine safety, medical and mental health training.
Policies and procedures should cover
Injuries, physical complaints and symptoms.
Dispensing, monitoring, changing and discontinuing medications.
Unusual, strange, or bizarre behavior.
Angry, aggressive, self-harming, threatening, violent or suicidal
Decompensation, failure to thrive and other forms of regressive
Medical crisis and emergencies (ex. dehydration, heat stroke,
hypothermia, sprains, lacerations, etc
Unusual and unexpected weather or potential natural disasters (ex.
lightning storms, cold snaps, wind storms, snow storms, wild fires, floods, extreme heat
Situations in which a student "runs" from the program, leaves
without permission, becomes lost or is missing.
Admissions are supervised and screened by an experienced,
qualified and licensed mental health professional.
Many parents exploring the options of wilderness and outdoor
therapeutic programs have not received comprehensive mental health services for their
children. Prior to exploring the wilderness program option, parents have often experienced
frustrating encounters with insurance companies, HMOs, or mental health or medical
providers. Parents are often not well informed by their health care providers and lack a
clear understanding of their childs problems. Understanding the childs needs
and clarity about the information necessary to identify and select an appropriate program
for that child is essential to informed parental choice. Determining whether or not a
particular child will benefit from a particular wilderness program is the most important
focus of any pre-admission process. The structure of the program and the therapeutic
activities must be appropriate. The intensity, duration, frequency and type of therapeutic
activities must be matched with the specific needs of a potential student. Primary
concerns are to avoid decompensation, failure to thrive and failure to benefit.
The idea that any one program can serve the needs of all prospective students is
absurd. Placing a student in an appropriate program and assuring there will be a clear
therapeutic plan will be more certain if oversight for admissions is the responsibility of
an experienced, qualified and licensed mental health professional.
At a minimum,
The program should identify the consulting medical care providers where
physical and medical care will be provided.
The medical screening should be outlined. A minimum medical screening
would include a physical examination, blood work, complete chemistries, as well as a drug
and alcohol screening.
The student's intake process should include a comprehensive biological,
psychological and social interview including individual and family history.
The procedure by which psychological evaluations would normally used
should be identified. Intensive evaluations normally include personality, intelligence,
achievement and neuropsychological functions.
Programs should publish position papers or policies and procedures if
they accept or may encounter students with emotional or psychiatric problems.
(See Screening Procedures for Wilderness Programs - Coming Soon)
Clinical, family and therapeutic activities in the program are
supervised by an experienced, qualified and licensed professional with training in
psychological, social and behavioral science.
Whether considering a wilderness program, a psychiatric hospital, a
residential treatment program or a boarding school, it is increasingly difficult for
consumers to be assured that a given therapy or treatment program is safe, effective and
humane in its work with children and families. Government regulation and licensing
of a program cannot alone provide the level of assurance that parents need. Government
regulation programs provide quality assurance in only the broadest terms. Parents can find
the highest level of assurance when there are experienced, qualified and licensed
professionals working in the program who are professionally responsible to oversee and
direct any activities that are considered therapeutic or clinical in nature. These
professionals might have the title of Program Director or Program Supervisor. By virtue of
their professional license and clear job descriptions, Directors or Supervisors of
Clinical, Family and Therapeutic Services would be required by their job description and
licensing law to follow standards of practice, ethical guidelines, state laws and
administrative rules that are a condition of licensure.
For professional and legal reasons, licensed mental health
professionals should not make referrals to programs that do not have licensed
professionals who are responsible for admissions, evaluations and therapeutic activities.
Whether it is a residential treatment program, or a wilderness therapy program, a licensed
professional should be given ultimate responsibility and authority for admissions,
confidentiality, standards of practice, following state laws, ethics, liability, therapy,
counseling and quality assurance. These responsibilities are distinctly separate from
those activities that are operational (e.g. logistics, safety, transportation, food,
water, personnel, supervision and training of field staff, clothing, equipment,
maintenance, coordination, maintenance). Operational responsibilities are routinely and
primarily those of a Field Director or Operations Director.
A distinction between unlicensed paraprofessionals, licensed
professionals who provides therapy or counseling services, and the role of a licensed
Director who is responsible for these services must be clearly defined by program
policies. A licensed Director or Supervisor of clinical, family and therapeutic activities
for a wilderness program can be held legally responsible for program policies, procedures
and the behavior of individuals providing clinical, family and therapeutic services. They
are also responsible for the activities of professionals and paraprofessionals. A Director
who has responsibility in title but who lacks authority within the structure of the
organization is not able to function professionally. Professionals must seek authority
commensurate with their professional obligations. When they are unable or not allowed to
insure that professional standards will be followed, they should separate from these
Under no circumstances should unlicensed paraprofessionals provide
professional supervision of licensed professionals. A line of authority must be clear.
Parents and professionals referring to programs must understand who is responsible for the
safety and emotional well-being of their children as well as their qualifications. Honest
and complete disclosure is an ethical and legal requirement. Paraprofessionals should not
have ultimate responsibility for clinical and therapeutic activities.
A therapist, counselor or paraprofessional employed by the program
is responsible to follow or to challenge program policies and procedures. Their scope of
responsibilities are not as broad as those of a Director. A Director with a clear job
description can be held responsible for negligent policies, including the absence of
important policy, as well as a failure to oversee policies necessary to insure the safety
and psychological well-being of students. As much as 80% of all activities and staff
interactions with students are potentially therapeutic and should involve continuous
evaluation. The clinical Director should
Supervise clinical, family and therapeutic activities in the
Develop and monitor policies and procedures that insure the
health, safety and progress of students while enrolled in the program
Have program responsibility to oversee and insure that students
on medications are appropriately monitored and that medication benefits outweigh potential
risks and side effects
Coordinate with medical professionals and insure that medical
follow-up is implemented correctly
Insure monitoring of students for unacceptable and dangerous
Have line authority and the ability to intercede with respect to
all professional and paraprofessional interactions with students.
A written program policy and procedure that is updated on a
Policies and procedure documents provide a good assurance that a
program can be held accountable for inappropriate or potentially dangerous activities and
actions by employees. These procedures are only effective if staff are properly trained
and when staff are required to follow program policies and procedures. Policies place
expectations on the program and the staff. Failures to follow clearly defined policies and
procedures give parents the opportunity to raise issues, and if necessary, bring legal
actions for negligent behavior. As such, clear and thorough policies and procedures can be
an excellent safety consideration. Policies and procedures should include.
Student rights, responsibilities and discipline. Students and
parents should be given a summary document that clearly describes what is expected of
students, what rights they have and how students are challenged, encouraged, helped and
Methods to supervise and monitor student behavior and progress. A
student's progress should be monitored and documented on a daily basis in order to insure
students are thriving and to avoid decompensation or a failure to thrive. Parents should
be advised as to their child's progress orally or in writing on a weekly basis. At a
minimum, parents should be advised as to their child's physical, psychological and social
status. Measures of progress and success should be included in weekly reports.
Minimum staff training requirements (e.g. First Aid, CPR, WFR -
wilderness first responder training, radio communications, search and rescue). There has
been a recurrent observation by employees in wilderness therapy programs that some
companies hire some staff to "baby-sit" students. A program should not hire
staff to act as "warm bodies" to keep their staff to student ratios looking
good. Staff should be trained, both formally and informally on a continuing program of
Quality assurance activities and practices. Quality assurance
must be the responsibility of a licensed professional who is experienced and qualified to
implement a quality assurance program. Quality assurance can be implemented by
paraprofessionals, but must be supervised by professionals.
Reporting procedures for child abuse. Child abuse reporting
procedures must be provided to parents prior to enrollment. Failure to do so is unethical
and even illegal in some states. In some states, a licensed professional may lose their
license if they do not provide full and complete information.
The limitations of what can be considered confidential. Some
communication may be related between student and parents by their child's therapist or
counselor. Parents and students should be told in advance how information will be handled.
Students and parents have confidentiality rights. These should be clearly described and
Minimum staff experience requirements. Staff should be screened
and employed on the basis of education, interpersonal and outdoor skills. At a minimum,
staff should have wilderness survival experience, training in outdoor skills, education,
ideally they should have prior work experience in similar programs.
Risk management and safety program. Near accidents or potentially
dangerous problems should be routinely investigated, reviewed and documented in order to
assure that the program will be proactive in preventing further accidents or injuries.
Recommendations including training as well as new policies and procedures should be
implemented in timely manner.
The program provides full and complete informed consent to
parents when they contact the program.
Staff members should identify their position and qualifications when
they introduce themselves to parents and professionals who are seeking information about
The program should clearly state the limits of privacy,
confidentiality and legal privileges that protect students and parents.
The experience, qualifications and licensure of the person
responsible for students medical and psychological well-being including safety must
The program description should clearly state any registration or
license to operate as a school or treatment program and define which state laws or
licensure requirements will insure responsible program operation and hold the program
accountable. A brief description of what each licenses or and registration signifies and
how it is regulated should be included in the written program description.
The program should describe procedures that will take place if a
student becomes lost, walks or runs away from the program without permission from the
program or parents.
Additional Risk Factors
In addition to the above factors, there are a host of considerations
that can be important when considering and exploring a wilderness therapy and intervention
program. This list is not exhaustive, but is fairly comprehensive.
Program therapeutics are clearly understood. The structure of the
program and the therapeutic activities should not simply be copied from other programs.
The owners and employees operating the program and providing services must understand the
psychological principles and social science that underlie all therapeutic activities. The
risk and benefits of therapeutic activities can not be assumed because they are common
practices in other programs.
Comprehensive crisis intervention. Crisis interventions and
evaluations of unusual or threatening behavior by students must be implemented, supervised
and documented by an experienced, qualified and licensed mental health professional.
Paraprofessionals should not supervise crisis interventions and evaluations. All
behavior that represents a potential high risk must be evaluated and resolved in a
professional and appropriate manner.
Comprehensive counseling and treatment planning. There must be
individual evaluation, counseling and treatment plans routinely developed for students
that cover a students history, medical status, diagnosis if any, medications if any,
problems to be addressed, educational, counseling and treatment recommendations, as well
as plans for the student after they graduate. Position papers on
are highly recommended. This should help organize and direct services in light of
Tuition is adequate and reasonable. The average cost of the
program per student should not be less than $170 per day. (Based on the economics of 1999)
This does not mean that parents should be charged more. This figure is based on an
estimated minimum cost to provide essential services. When the cost of a program is below
this level (plus or minus 15%), there can be difficulty staffing the program and providing
the necessary level of training, supervision, quality assurance and support for both staff
Timely medical screening and services. Students should not be
admitted without a timely medical screening. This would involve a medical screening prior
to enrollment when indicated or a medical screening within the first 2 weeks. An informal
health screen prior to admission is essential to identify obvious potential problems.
Qualified and experienced field staff. Instructors should
have more than six months experience working in the field program or a similar program
before they become Head Instructors. Head instructors should have experience working and
living outdoors for extended periods in wilderness guide or leadership positions.
Extensive outdoor and survival experience should be required in order for staff to work
with students in harsh environmental conditions.
Staff have diverse and valuable life experience. The program
should have a wide range of life experience represented in their staff. This should
include education, work experience, life experience and experience working with youth at
risk. For example, at least 50% of program field instructors should be at least 25 years
old. At least 25% of program staff and instructors should be at least 30 years old. There
should be staff in the company who are raising families of their own. Staff who had
problems similar to students can be an asset but these staff should have worked through
their problems successfully so that they can be examples and role models. Cultural
diversity and ethnicity are especially valuable learning resources for students. Staff
with college and advanced degrees can provide a valuable perspective for students.
Policies should prohibit dual relationships. The program should
have a clear policy that forbids employees and owners from accepting gifts, money, special
business deals and from entering into financial relationships with parents while their
child is enrolled. Such behavior creates a potential conflict of interest and undermines
the program's ability to provide a neutral and objective perspective to one or both
parents. The problem of special or dual relationships is especially difficult when
students parents are divorced, their relationship is conflicted and custody of the
child is an issue.
Economically feasible. The company should be well enough funded
to cover their payroll and operating expenses. Under funded programs may be unable to
provide the level of staffing and services necessary to insure program safety. Non-profits
must disclose their financial status. For-profit companies are not required to disclose
their financial status but will usually answer questions. Refusal to respond to such
questions may be a warning sign of under funding.
Adequate liability coverage. Business and professional indemnity
insurance should be comprehensive and in full force. Insurance should cover all
operations, equipment and therapeutic services. Insurance limits should be a minimum of
one million dollars per loss incident, 3 million dollars aggregate.
Steps That Parents, Mental Health Professionals and Educational
Consultants Should Take
At some point the following information should be requested and
reviewed before a student is enrolled in a program. Parents may research the issues
identified above for them selves or they might obtain consultation services from an
educational consultant or mental health professional who is familiar with outdoor and
wilderness therapy programs. Professionals who refer to wilderness therapy programs will
often have specific knowledge and experience with many types of programs. The following
information should be made available from the program by mail or on the Internet. Ask for
a printed copy to review. Ideally, the program should have information and documents
1. The programs policies and procedures that cover
Employee hiring practices including reference and background checks
Routine drug and alcohol screening of staff
Inappropriate and forbidden behavior by staff and program management
The exceptions and limitations of confidentiality
Routine, urgent and emergency medical and mental health procedures
Proactive responses that staff is trained to take in response to
inappropriate and dangerous behavior by students
Admissions and screening procedures and the qualifications of the staff
involved in the admission process
Routine and periodic program activities that take place in the field
Program activities and personnel that support, monitor and supervise
Quality assurance, safety and risk management procedures that describe
what will happen with regard to incidents, accidents or other behavior that would be of
concern to parents
The procedure and time line by which parents will be notified of any
accident, injury, medical problem, students leave the program, abuse or allegations of
inappropriate or potentially abusive behavior
Communication procedures by radio and telephone. This includes
procedures that will be followed in the event that a student runs, becomes lost or
missing. Procedures should be outlined for situations where the program or field staff
lose contact with each other or routine daily check in procedures fail
The risk management program, policy and procedures, threshold of risk to
activate the program, committee members, review process and the procedures to document and
Psychological and psychiatric evaluation services including evaluation,
testing, counseling and psychotherapy services
2. An overview of the job description and brief resumes for
The Chief Executive Officer or person responsible for the overall
Director of Field Operations, or The Chief Operations Officer
The Operations Manager
The Section Director or Field Manager
The Director of Family, Clinical and Therapeutic Services, or the
Clinical Program Supervisor
The Director of Admissions or Admissions Coordinator
Head Instructors and Assistant Instructors
The quality assurance professional
All teachers and assistant teachers
Program therapists, counselors, residents or interns
Instructors and Head Instructor (or Field Guides)
Support staff including drivers, backup staff, and administrative
3. The programs educational and therapeutic philosophy, evaluation and
testing services and the use of specific therapeutic activities including
Medical and mental health education
Individual counseling or therapy
Group counseling or therapy
Trust games and activities
Socialization, leadership and team building
Initiatives, challenges and ordeals
Discipline, behavioral requirements, reinforcements and consequences
Excluded or inappropriate counseling approaches and therapy techniques
Testing, evaluation, assessment and interview procedures
copyright 1999 - 2002, Michael G. Conner