1. Results from Open Skys Outcome Research Joanna Bettmann, Ph.D, LCSW Open Sky Wilderness Therapy December, 2009

2. Outline of the Presentation Why do research? Why do research? Defining wilderness therapy Defining wilderness therapy Existing outcome research into wilderness therapy Existing outcome research into wilderness therapy Open Skys outcome research on adolescents and young adults Open Skys outcome research on adolescents and young adults

3. Why do research? There are at least 10,000 adolescents in wilderness treatment each year (Cooley, 1998) There are at least 10,000 adolescents in wilderness treatment each year (Cooley, 1998) Thus, we must have research which shows that wilderness therapy is effective

4. What is Wilderness Therapy? Russell (2003) defines wilderness therapy as a type of program that works to address problem behaviors...through a variety of therapeutic and educational curricula in outdoor environments. [This] process is facilitated by licensed professionals (p. 3). Russell (2003) defines wilderness therapy as a type of program that works to address problem behaviors...through a variety of therapeutic and educational curricula in outdoor environments. [This] process is facilitated by licensed professionals (p. 3). What wilderness therapy is not: What wilderness therapy is not: Challenge courses Challenge courses Adventure based therapy Adventure based therapy Boot Camp Boot Camp (Russell, 2001) (Russell, 2001)

5. What do we already know about the effectiveness of wilderness therapy? Using the Youth Outcome Questionnaire, Russell (2003) studied 858 adolescent clients and their parents in 7 different wilderness therapy programs: he found significant gains made during treatment which was largely maintained at 1 –year follow-up Using the Youth Outcome Questionnaire, Russell (2003) studied 858 adolescent clients and their parents in 7 different wilderness therapy programs: he found significant gains made during treatment which was largely maintained at 1 –year follow-up Russell (2005) followed up at 2 years with 88 parents from the original sample and 47 adolescents: gains made during treatment were largely maintained 2 years after wilderness program Russell (2005) followed up at 2 years with 88 parents from the original sample and 47 adolescents: gains made during treatment were largely maintained 2 years after wilderness program Harper, Russell, Cooley & Cupples (2007) conducted a quantitative, longitudinal study of 252 adolescents at Catherine Freer: showed positive improvement after 21-day wilderness program Harper, Russell, Cooley & Cupples (2007) conducted a quantitative, longitudinal study of 252 adolescents at Catherine Freer: showed positive improvement after 21-day wilderness program Bettmann (2007) studied changes in the attachment relationships of 93 adolescents in wilderness treatment: showed adolescents less angry at parents following treatment Bettmann (2007) studied changes in the attachment relationships of 93 adolescents in wilderness treatment: showed adolescents less angry at parents following treatment

6. Other recent wilderness therapy outcome research Cook (2008) completed a qualitative study of 13 male adolescents in a year-long residential wilderness therapy program Cook (2008) completed a qualitative study of 13 male adolescents in a year-long residential wilderness therapy program Eikenæs, Gude & Hoffart (2006): compared a 6-day wilderness treatment versus standard inpatient hospitalization for adults with avoidant personality disorder Eikenæs, Gude & Hoffart (2006): compared a 6-day wilderness treatment versus standard inpatient hospitalization for adults with avoidant personality disorder Gillis, Gass & Russell (2008): studied the effectiveness of project adventures behavior management programs for male offenders in residential treatment Gillis, Gass & Russell (2008): studied the effectiveness of project adventures behavior management programs for male offenders in residential treatment Jones, Lowe & Risler, (2004): studied 24 boys in wilderness treatment compared to 11 in group homes (in Juvenile Justice system) Jones, Lowe & Risler, (2004): studied 24 boys in wilderness treatment compared to 11 in group homes (in Juvenile Justice system) Sklar, Anderson & Autry (2007) studied 15 at-risk youth who participated in an 8-day therapeutic wilderness canoe trip Sklar, Anderson & Autry (2007) studied 15 at-risk youth who participated in an 8-day therapeutic wilderness canoe trip Caulkins, White & Russell (2006) qualitatively studied the role of backpacking and physical exercise in 6 adolescent girls in a wilderness therapy program Caulkins, White & Russell (2006) qualitatively studied the role of backpacking and physical exercise in 6 adolescent girls in a wilderness therapy program Russell & Harper (2006) studied restraint, runaway, illness and injury incidents over 4 years of OBHIC member programs Russell & Harper (2006) studied restraint, runaway, illness and injury incidents over 4 years of OBHIC member programs

7. Research shows positive outcomes for wilderness treatment Improved mental health symptomology Improved mental health symptomology Sense of accomplishment Sense of accomplishment Increased self-esteem Increased self-esteem Sense of empowerment Sense of empowerment Better access to feelings Better access to feelings Improved relationships Improved relationships Improved communication skills Improved communication skills Improved drug & alcohol awareness Improved drug & alcohol awareness Improved coping skills Improved coping skills Awareness of behaviors Awareness of behaviors (Bettmann, 2007; Russell, 2001, 2003, 2005; Russell, Hendee, & Phillips-Miller, 2000)

8. Adult Outcome Research: Sparse Hyer (1996): study of adult participants of Outward Bound program. Participants reported gains in self-esteem, problem-solving and behavior change Hyer (1996): study of adult participants of Outward Bound program. Participants reported gains in self-esteem, problem-solving and behavior change Goldenberg (2005): study of adult participants of another Outward Bound program. Participants reported improved self esteem, confidence and interpersonal skills. Goldenberg (2005): study of adult participants of another Outward Bound program. Participants reported improved self esteem, confidence and interpersonal skills. Asher, Huffaker & McNally (1994): study of adult abuse survivors on 3-day wilderness therapy trip. Study reports participants developed trusting relationships and utilized problem-solving skills. Asher, Huffaker & McNally (1994): study of adult abuse survivors on 3-day wilderness therapy trip. Study reports participants developed trusting relationships and utilized problem-solving skills. Little research on adult outcomes (Kelly, 2006; Paxton, 2000) Little research on adult outcomes (Kelly, 2006; Paxton, 2000)

9. Problems in Wilderness Outcome Research Poor treatment definition (Russell, 2001) Few outcome studies, few in peer-reviewed literature No accounting for programmatic elements or delivery Open Skys study attempts to ameliorate these flaws in the literature

10. Open Sky Outcome Research: Three Years of Conclusive Data Data gathered from all students and their parents/stepparents/caretakers Data gathered from all students and their parents/stepparents/caretakers Data gathered on the first day of Open Sky program, last day of Open Sky program, 3 months after, 6 months after, 12 months after, and 24 months after Data gathered on the first day of Open Sky program, last day of Open Sky program, 3 months after, 6 months after, 12 months after, and 24 months after This is an exploratory study to answer the questions: is this wilderness treatment effective? What factors are associated with positive outcomes? This is an exploratory study to answer the questions: is this wilderness treatment effective? What factors are associated with positive outcomes?

11. Comparing Open Sky Results to other Wilderness Therapy Programs This graph shows that teens graduating from Open Sky have done better at graduation and one year later than teens who go to other wilderness therapy programs. This graph shows that teens graduating from Open Sky have done better at graduation and one year later than teens who go to other wilderness therapy programs.

12. The Open Sky model of wilderness therapy Holistic focus: treating the whole person Holistic focus: treating the whole person Typically one group of 7 clients with 3 staff Typically one group of 7 clients with 3 staff Masters or Doctoral level counselors visit 2 days/week to provide sophisticated individual/group psychotherapy Masters or Doctoral level counselors visit 2 days/week to provide sophisticated individual/group psychotherapy Counselors talk with families on the phone, create individualized treatment plans, coordinate family treatment Counselors talk with families on the phone, create individualized treatment plans, coordinate family treatment Organic, whole foods diet Organic, whole foods diet Daily activities: group hikes, group Daily activities: group hikes, group therapy, learning primitive skills, experiential curriculum, meditation, yoga Initial medical and clinical screening, ongoing naturopathic treatment Initial medical and clinical screening, ongoing naturopathic treatment Psychiatric consultations as needed Psychiatric consultations as needed

13. Open Sky Outcome Research: Measurements/Questionnaires Adolescent Measures Youth Outcome Questionnaire (YOQ) (Burlingame, Wells & Lambert, 1995) Youth Outcome Questionnaire (YOQ) (Burlingame, Wells & Lambert, 1995) Adolescent Attachment Questionnaire (West, Rose, Spreng, Sheldon-Keller & Adam, 1998) Adolescent Attachment Questionnaire (West, Rose, Spreng, Sheldon-Keller & Adam, 1998) Adolescent Relapse Coping Questionnaire (ARCQ) (Myers & Brown, 1996) Adolescent Relapse Coping Questionnaire (ARCQ) (Myers & Brown, 1996) University of Rhode Island Change Assessment (URICA) (McConnaughy, Prochaska & Velicer, 1983) University of Rhode Island Change Assessment (URICA) (McConnaughy, Prochaska & Velicer, 1983) Young Adult Measures Outcome Questionnaire-45 (OQ) (Lambert & Burlingame, 1996) University of Rhode Island Change Assessment (McConnaughy, Prochaska & Velicer, 1983) Adult Attachment Scale Addictive Disorders Screen – Revised (Howatt, 2006) Psychological Separation Inventory (Hoffman, 1984)

14. Open Sky Study: Teen Numbers Gender Gender 100 male students (47.6%) 100 male students (47.6%) 110 female students (52.4%) 110 female students (52.4%) Average number of days in the program Average number of days in the program 63.07 days 63.07 days Average age at admit = 15.81 years old Average age at admit = 15.81 years old Age range is 13-17 years old Age range is 13-17 years old Did you go on to Aftercare after Open Sky? Did you go on to Aftercare after Open Sky? 122 = yes (67%) 122 = yes (67%) 60 = no (33%) 60 = no (33%)

15. Open Sky Study: Teen Characteristics Race Race 158 white students (85.9%) 158 white students (85.9%) 24 students of color (13.2%) 24 students of color (13.2%) Adopted Adopted 32 adopted students (18%) 32 adopted students (18%) 146 non-adopted students (82%) 146 non-adopted students (82%) Clinical Issues in all Teen Students Clinical Issues in all Teen Students Substance Abuse or Dependence = 70.6% of all teen students Substance Abuse or Dependence = 70.6% of all teen students Depressive Disorders/Anxiety Disorders/Bipolar Disorders = 72.7% Depressive Disorders/Anxiety Disorders/Bipolar Disorders = 72.7% ADHD/Oppositional Defiant Disorder/Disruptive Behavior = 61.8% ADHD/Oppositional Defiant Disorder/Disruptive Behavior = 61.8%

16. Summary of Open Sky Teens Mental Health Distress Summary of Open Sky Teens Mental Health Distress The next few slides present the results of the Youth Outcome Questionnaire (YOQ) results, which report on adolescents mental health distress and how it changed as a result of the program The next few slides present the results of the Youth Outcome Questionnaire (YOQ) results, which report on adolescents mental health distress and how it changed as a result of the program

17. The Youth Outcome Questionnaire (YOQ): What does it specifically measure? Emotional distress (anxiety, depression, fear, hopelessness, self- harm) Emotional distress (anxiety, depression, fear, hopelessness, self- harm) Physical distress (headaches, dizziness, stomachaches, nausea, etc.) Physical distress (headaches, dizziness, stomachaches, nausea, etc.) Relationship issues with parents, other adults, peers (attitude, cooperativeness, aggressiveness, arguing) Relationship issues with parents, other adults, peers (attitude, cooperativeness, aggressiveness, arguing) Social problems (conduct, aggression, truancy, runaway, sexual problems, vandalism) Social problems (conduct, aggression, truancy, runaway, sexual problems, vandalism) Behavioral problems (ability to organize, complete tasks, inattention, hyperactivity) Behavioral problems (ability to organize, complete tasks, inattention, hyperactivity) Other items (paranoia, obsessions and compulsions, hallucinations, delusions, suicidal ideation, mania, eating disorder ) Other items (paranoia, obsessions and compulsions, hallucinations, delusions, suicidal ideation, mania, eating disorder )

18. Open Sky Parent of Teen Results Over Time This graph shows that parents of Open Sky teens report their children improve emotionally and behaviorally by graduation from Open Sky and these improvements remain steady over the course of a year.

19. Comparing Open Sky Parent and Teen Scores Over Time This graph shows that Open Sky teens report they improve emotionally and behaviorally from the first day to the last day at Open Sky and that these improvements in mental health are steadily maintained over time.

20. Summary of Adolescent Relapse Coping Questionnaire The next few slides present the latest results of the Adolescent Relapse Coping Questionnaire (ARCQ) which predicts future substance use by measuring substance abuse recovery skills The next few slides present the latest results of the Adolescent Relapse Coping Questionnaire (ARCQ) which predicts future substance use by measuring substance abuse recovery skills

21. Adolescent Relapse Coping Questionnaire (ARCQ): What does it specifically measure? Higher scores of abstinence-focused thoughts of drugs and alcohol predict less substance abuse at 1 year after treatment. Higher scores of abstinence-focused thoughts of drugs and alcohol predict less substance abuse at 1 year after treatment. Lower scores of self critical thoughts correlate with less substance use, better coping, and higher self-esteem and self-efficacy Lower scores of self critical thoughts correlate with less substance use, better coping, and higher self-esteem and self-efficacy

22. Open Sky Teens Recovery from Substance Abuse This graph shows that Open Sky teens report an increase in Abstinence-Focused Coping skills, meaning that they gain skills for resisting substance abuse while at Open Sky and maintain those gains for a year after treatment. This graph shows that Open Sky teens report an increase in Abstinence-Focused Coping skills, meaning that they gain skills for resisting substance abuse while at Open Sky and maintain those gains for a year after treatment.

23. Summary of Adolescent and Young Adult Readiness to Change The next few slides present the latest results of teen and young adult readiness for change as measured by the University of Rhode Island Change Assessment (URICA) The next few slides present the latest results of teen and young adult readiness for change as measured by the University of Rhode Island Change Assessment (URICA)

24. University of Rhode Island Change Assessment (URICA): What does it specifically measure? The URICA assesses how ready and willing a person is to change the problem(s) in ones life. The URICA assesses how ready and willing a person is to change the problem(s) in ones life. Higher scores mean more readiness and willingness to change ones life. Higher scores mean more readiness and willingness to change ones life.

25. Open Sky Teen Readiness and Willingness to Change Over Time This graph shows that Open Sky teens attitudes about his/her readiness to change their problems improves over time. This graph shows that Open Sky teens attitudes about his/her readiness to change their problems improves over time. This graph also shows that these improvements steadily increase up to one year after Open Sky graduation, indicating increased willingness to face problems and make changes. This graph also shows that these improvements steadily increase up to one year after Open Sky graduation, indicating increased willingness to face problems and make changes.

26. Open Sky Adult Readiness and Willingness to Change Over Time This graph shows that Open Sky adults attitudes about changing their problems improves from first day to graduation day. This graph shows that Open Sky adults attitudes about changing their problems improves from first day to graduation day.

27. Open Sky Study: Young Adult Numbers Total number of participants =114 Total number of participants =114 Gender Gender Male = 68.4% Male = 68.4% Female = 31.6% Female = 31.6% Age Age Average = 20 years old Average = 20 years old Range = 17-29 years old Range = 17-29 years old Number of days in program Number of days in program Range 4-83 Range 4-83 Average = 54.73 days Average = 54.73 days Go on to aftercare after Open Sky Go on to aftercare after Open Sky Yes = 64.3% Yes = 64.3% No = 35.7% No = 35.7%

28. Open Sky Study: Young Adult Characteristics Adopted Adopted Yes = 14.4% Yes = 14.4% No = 85.6% No = 85.6% Race Race White = 92.3% White = 92.3% Students of color = 6.6% Students of color = 6.6% Clinical Profiles of all Young Adult Students Clinical Profiles of all Young Adult Students Substance abuse/dependence = 71.2% Substance abuse/dependence = 71.2% Depressive Disorders/Anxiety Disorders/Bipolar Disorders = 88.1% Depressive Disorders/Anxiety Disorders/Bipolar Disorders = 88.1% ADHD/Oppositional Defiant Disorder/Disruptive Behavior = 40.7% ADHD/Oppositional Defiant Disorder/Disruptive Behavior = 40.7%

29. Emotional distress (anxiety, depression, fear, hopelessness, self-harm) Emotional distress (anxiety, depression, fear, hopelessness, self-harm) Relationships (satisfaction with, as well as problems in interpersonal relations) Relationships (satisfaction with, as well as problems in interpersonal relations) Social role (assesses level of dissatisfaction, conflict, distress and inadequacy in tasks related to employment, family roles and leisure life) Social role (assesses level of dissatisfaction, conflict, distress and inadequacy in tasks related to employment, family roles and leisure life) The Adult Outcome Questionnaire (OQ): What does it specifically measure?

30. Open Sky Adult Levels of Distress Over Time This graph shows that Open Skys young adults report improved mental health by the end of Open Sky treatment. This graph shows that Open Skys young adults report improved mental health by the end of Open Sky treatment.

31. What factors have been found to effect Open Sky Teen and Adult success? Open Sky teens who go on to aftercare tend to sustain better mental health and behavior over time. Open Sky teens who go on to aftercare tend to sustain better mental health and behavior over time. Open Sky is equally effective for all genders and races. Open Sky is equally effective for all genders and races. Open Sky is effective for adolescents and young adults. Open Sky is effective for adolescents and young adults. Open Sky is effective for people with a wide range of problems including Open Sky is effective for people with a wide range of problems including mood, behavioral, relational, and substance use problems. Adopted teens and their parents tend to disagree more than non-adopted families on levels of mental health distress upon arrival. Adopted teens and their parents tend to disagree more than non-adopted families on levels of mental health distress upon arrival.

32. Teen Reported Differences in going to Aftercare vs. going Home This graph shows that teens who go to aftercare after Open Sky report fewer mental health problems than teens who went home after Open Sky. This graph shows that teens who go to aftercare after Open Sky report fewer mental health problems than teens who went home after Open Sky.

33. Parent Reported Differences of Teens who go to Aftercare vs. go Home This graph shows that parents of teens who go on to aftercare after Open Sky believe their children do better over time than parents of teens who went home after Open Sky. This graph shows that parents of teens who go on to aftercare after Open Sky believe their children do better over time than parents of teens who went home after Open Sky.

34. Open Sky Conclusions There is strong evidence that Open Sky Wilderness Therapy works There is strong evidence that Open Sky Wilderness Therapy works Open Sky is effective for a range of clinical diagnoses, ages, genders and characteristics Open Sky is effective for a range of clinical diagnoses, ages, genders and characteristics Preliminary evidence from Open Sky study suggests that aftercare offers a protective factor in long term success following wilderness therapy treatment Preliminary evidence from Open Sky study suggests that aftercare offers a protective factor in long term success following wilderness therapy treatment

35. Open Sky Research References Asher, S.J., Huffaker, G.Q., & McNally, M. (1994). Therapeutic considerations of wilderness experiences for incest and rape survivors. Women & Therapy, 15 (3/4), Asher, S.J., Huffaker, G.Q., & McNally, M. (1994). Therapeutic considerations of wilderness experiences for incest and rape survivors. Women & Therapy, 15 (3/4), 161-174. 161-174. Autry, C.E. (2001). Adventure therapy with girls at-risk: responses to outdoor experiential activities. Therapeutic Recreation Journal, 35(4), 289-306. Berman, D.S. & Anton, M.T. (1988). A wilderness therapy program as an alternative to Berman, D.S. & Anton, M.T. (1988). A wilderness therapy program as an alternative to adolescent psychiatric hospitalization. Residential Treatment for Children & Youth, 5(3), 41-53. Bettmann, J.E. (2007). Changes in adolescent attachment relationships as a response to Bettmann, J.E. (2007). Changes in adolescent attachment relationships as a response to wilderness treatment. Journal of the American Psychoanalytic Association, 55 (1), 259-265. Burlingame, G.M., Wells, M.G. & Lambert, M.J. (1995). The Youth Outcome Questionnaire. Stevenson, MD: American Professional Credentialing Services. Caulkins, M.C., White, D.D., & Russell, K.C. (2006). The Role of physical exercise Caulkins, M.C., White, D.D., & Russell, K.C. (2006). The Role of physical exercise in wilderness therapy for troubled adolescent women. Journal of Experiential Education, 29(1), 18-37. Conner, M. (2007, March 5). An Overview of wilderness therapy programs. Retrieved from http://www.wildernesstherapy.org/Wilderness/WildernessProgramOverview.html Conner, M. (2007, March 5). An Overview of wilderness therapy programs. Retrieved from http://www.wildernesstherapy.org/Wilderness/WildernessProgramOverview.html

36. Open Sky Research References Connor, D.F., Miller, K.P., Cunningham, J.A., & Melloni, R.H. (2002). What does getting Connor, D.F., Miller, K.P., Cunningham, J.A., & Melloni, R.H. (2002). What does getting better mean? Child improvement and measure of outcome in residential treatment [Electronic version]. American Journal of Orthopsychiatry, 72 (1), 110-117. Cook, E.C. (2008). Residential wilderness programs: the role of social support in influencing self- evaluations of male adolescents. Adolescence, 43(172), 751-773. Cooley, R. (1998). Wilderness therapy can help troubled adolescents. International Journal of Wilderness, 4(3), 18-21. Cooley, R. (1998). Wilderness therapy can help troubled adolescents. International Journal of Wilderness, 4(3), 18-21. Courtney, M.E. (2000). Research needed to improve the prospects for children in out-of-home Courtney, M.E. (2000). Research needed to improve the prospects for children in out-of-home placement. Children and Youth Services Review, 22 (9/10), 743-761. Curry, J.F. (1991). Outcome research on residential treatment: Implications and suggested directions. American Journal of Orthopsychiatry, 61 (3), 348-357. Curry, J.F. (1991). Outcome research on residential treatment: Implications and suggested directions. American Journal of Orthopsychiatry, 61 (3), 348-357. Edwards, J.K. (1994). Children in residential treatment: How many, what kind? Do we really Edwards, J.K. (1994). Children in residential treatment: How many, what kind? Do we really know? In G. Northrup (Ed.), Applied research in residential treatment (pp. 85-99). New York, NY: The Haworth Press, Inc. Ekineas, I., Gude, T., & Hoffart, A. (2006). Integrated wilderness therapy for avoidant personality disorder. Nord J Psychiatry, 60(4), 275-281 Ekineas, I., Gude, T., & Hoffart, A. (2006). Integrated wilderness therapy for avoidant personality disorder. Nord J Psychiatry, 60(4), 275-281 Ewert, A.W., McCormick, B.P., & Voight, A.E. (2001). Outdoor experiential therapies: implications for tr practice. Therapeutic Recreation Journal, 35(2), 107-122.

37. Open Sky Research References Foster, E.M. (2002). Modeling child and adolescent psychiatric hospital utilization: A framework for examining predictors of service use. Childrens Services: Social Policy, Research & Practice, 5 (3), 151- 173. Gillen, M.C., & Balkin, R.S. (2006). Adventure counseling as an adjunct to group counseling in hospital and clinical settings. The Journal for Specialists in Group Work, 31(2), 153-164. Gillen, M.C., & Balkin, R.S. (2006). Adventure counseling as an adjunct to group counseling in hospital and clinical settings. The Journal for Specialists in Group Work, 31(2), 153-164. Gillis, H.L., Gass, M.A., & Russell, K.C. (2008). The Effectiveness of project adventure. Residential Treatment for Children and Youth, 25(3), 227-247. Gillis, H.L., Gass, M.A., & Russell, K.C. (2008). The Effectiveness of project adventure. Residential Treatment for Children and Youth, 25(3), 227-247. Goldenberg, M., McAvoy, L., & Kenosky, D.B. (2005). Outcomes from the components of an Outward Bound Experience [Electronic version]. Journal of experiential education, 28 (2), 123-146. Goldenberg, M., McAvoy, L., & Kenosky, D.B. (2005). Outcomes from the components of an Outward Bound Experience [Electronic version]. Journal of experiential education, 28 (2), 123-146. Goodrich, W. (1994). Research issues in adolescent inpatient psychiatry. In Ghuman, H.S., & Sarles, R.M. (Eds.), Handbook of adolescent inpatient psychiatric treatment (pp. 277-292). New York, NY: Brunner/Mazel Publishers. Gorske, T.T., Srebalus, D.J., & Walls, R.T. (2003). Adolescents in residential centers: characteristics and treatment outcome. Children and Youth Services Review, 25(4), 317-326. Gorske, T.T., Srebalus, D.J., & Walls, R.T. (2003). Adolescents in residential centers: characteristics and treatment outcome. Children and Youth Services Review, 25(4), 317-326. Harper, N., & Cooley, R. (2006). Parental reports of adolescent and family well-being following a wilderness therapy intervention: an exploratory look at systemic change. Journal of Experiential Education, 29(3), 393-396.

38. Open Sky Research References Harper, N.J., Russel, K.C., Cooley, R., & Cupples, J. (2007). Catherine freer wilderness therapy expeditions: an exploratory case study of adolescent wilderness therapy, family functioning, and the maintenance of change. Child Youth Care Forum, 36, 111-129. Harper, N.J., Russel, K.C., Cooley, R., & Cupples, J. (2007). Catherine freer wilderness therapy expeditions: an exploratory case study of adolescent wilderness therapy, family functioning, and the maintenance of change. Child Youth Care Forum, 36, 111-129. Harper, N., & Scott, D.G. (2006). Therapeutic outfitting: enhancing conventional adolescent mental health interventions through innovative collaborations with a wilderness experience programme. Therapeutic Communities, 27(4), 548-570. Harper, N., & Scott, D.G. (2006). Therapeutic outfitting: enhancing conventional adolescent mental health interventions through innovative collaborations with a wilderness experience programme. Therapeutic Communities, 27(4), 548-570. Hill, N.R. (2007). Wilderness therapy as a treatment modality for at-risk youth: a primer for Hill, N.R. (2007). Wilderness therapy as a treatment modality for at-risk youth: a primer for mental health counselors. Journal of Mental Health Counseling, 29(4), 338-349. Hoffman, J.A. (1984). Psychological separation of late adolescents from their parents. Journal Hoffman, J.A. (1984). Psychological separation of late adolescents from their parents. Journal of Counseling Psychology, 31 (2), 170-178. Howatt, W.A. (2006). Addiction screening tools vs. addiction clinical measures: Introducing the Howatt, W.A. (2006). Addiction screening tools vs. addiction clinical measures: Introducing the Addiction Disorder Screen (ADS) -7. Counselor, 7 (1), 48-53. Hyer, L., Boyd, S., Scurfield, R., Smith, D., & Burke, J. (1996). Effects of Outward Bound experience as an adjunct to inpatient PTSD treatment of war veterans [Electronic version]. Journal of Clinical Psychology, 52 (3), 263-287.

39. Open Sky Research References Jones, C.D., Lowe, L.A., Risler, E.A. (2004). The effectiveness of wilderness adventure therapy Jones, C.D., Lowe, L.A., Risler, E.A. (2004). The effectiveness of wilderness adventure therapy programs for young people involved in the juvenile justice system. Residential Treatment for Children and Youth, 22(2), 53-67. Kaptian, J. (2003). Blazing new trails: adventure therapy for adolescents with eating disorders. Kaptian, J. (2003). Blazing new trails: adventure therapy for adolescents with eating disorders. American Journal of Recreation Therapy, 41-44. Kelly, V.A. (2006). Women of courage: a personal account of a wilderness-based experiential group for survivors of abuse [Electronic version]. Journal for Specialists in Group Work, 31 (2), 99-111. Kelly, V.A. (2006). Women of courage: a personal account of a wilderness-based experiential group for survivors of abuse [Electronic version]. Journal for Specialists in Group Work, 31 (2), 99-111. Larson, B.A. (2007). Adventure camp programs, self-concept, and their effects on behavioral problem adolescents. Journal of Experiential Education, 29(3), 313-330. Larson, B.A. (2007). Adventure camp programs, self-concept, and their effects on behavioral problem adolescents. Journal of Experiential Education, 29(3), 313-330. Lyons, J.S., Libman-Mintzer, L.N., Kisiel, C.L., & Shallcross, H. (1998). Understanding the mental health needs of children and adolescents in residential treatment. Professional Psychology: Research and Practice, 29(6), 582-587. Lyons, J.S., Libman-Mintzer, L.N., Kisiel, C.L., & Shallcross, H. (1998). Understanding the mental health needs of children and adolescents in residential treatment. Professional Psychology: Research and Practice, 29(6), 582-587. McConnaughy, E.N., Prochaska, J.O., & Velicer, W.F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368-375. Myers, M.G., & Brown, S.A. (1996). The Adolescent Relapse Coping Questionnaire: Psychometric validation. Journal of Studies on Alcohol, 57, 40-46.

40. Open Sky Research References Myers, M.G., & Brown, S.A. (1990a). Coping and appraisal in relapse risk situations among substance abusing adolescents following treatment. Journal of Adolescent Chemical Dependency, 1, 95- 115. Myers, M.G., & Brown, S.A. (1990a). Coping and appraisal in relapse risk situations among substance abusing adolescents following treatment. Journal of Adolescent Chemical Dependency, 1, 95- 115. Myers, M.G., & Brown, S.A. (1990b). Coping responses and relapse among adolescent substance abusers. Journal of Substance Abuse, 2, 177-189. Myers, M.G., & Brown, S.A. (1990b). Coping responses and relapse among adolescent substance abusers. Journal of Substance Abuse, 2, 177-189. Myers, M.G., & Brown, S.A. (1996). The Adolescent Relapse Coping Questionnaire: Psychometric validation. Journal of Studies on Alcohol, 57, 40-46. Myers, M.G., & Brown, S.A. (1996). The Adolescent Relapse Coping Questionnaire: Psychometric validation. Journal of Studies on Alcohol, 57, 40-46. Orren, P.M., & Werner, P.D. (2007). Effects of brief wilderness programs in relation to adolescents' race. Journal of Experiential Education, 30(2), 117-133. Orren, P.M., & Werner, P.D. (2007). Effects of brief wilderness programs in relation to adolescents' race. Journal of Experiential Education, 30(2), 117-133. Paxton, T., & McAvoy, L. (2000). Social psychological benefits of a wilderness adventure program [Electronic version]. USDA forest service proceedings RMRS-P-15, 3, 202-206. Paxton, T., & McAvoy, L. (2000). Social psychological benefits of a wilderness adventure program [Electronic version]. USDA forest service proceedings RMRS-P-15, 3, 202-206. Rosol, M. (2000, September). Wilderness therapy for youth-at-risk. Parks & Recreation, 42-52. Rosol, M. (2000, September). Wilderness therapy for youth-at-risk. Parks & Recreation, 42-52. Russell, K.C., Hendee, J.C., Phillips-Miller, D. (2000). How wilderness therapy works: An Russell, K.C., Hendee, J.C., Phillips-Miller, D. (2000). How wilderness therapy works: An examination of the wilderness therapy process to treat adolescents with behavioral problems and addictions. In D.N. Cole & S.F. McCool (Eds.), Proceedings from Wilderness Science in a Time of Change Conference. Fort Collins, CO: USDA, Forest Service, Rocky Mountain Research Station. (Proc. RMRS-P-15-vol. 3).

41. Open Sky Research References Russell, K.C. (2000). Exploring how the wilderness therapy process relates to outcomes. Journal of Experiential Education, 23(3), 170-176. Russell, K.C. (2000). Exploring how the wilderness therapy process relates to outcomes. Journal of Experiential Education, 23(3), 170-176. Russell, K.C. (2001). What is wilderness therapy? Journal of Experiential Education, 24 (2), 70-79. Russell, K.C. (2001). What is wilderness therapy? Journal of Experiential Education, 24 (2), 70-79. Russell, K.C. (2003a). An assessment of outcomes in outdoor behavioral healthcare treatment. Russell, K.C. (2003a). An assessment of outcomes in outdoor behavioral healthcare treatment. Child and Youth Care Forum, 32 (6), 355-381. Russell, K.C. (2003b, September). Definitions, models, and assessing outcomes in outdoor behavioral healthcare. In R. Meltzer (Chair), Wilderness Therapy Training and Symposium. Symposium conducted at Naropa University, Boulder, Colorado. Russell, K.C. (2003b, September). Definitions, models, and assessing outcomes in outdoor behavioral healthcare. In R. Meltzer (Chair), Wilderness Therapy Training and Symposium. Symposium conducted at Naropa University, Boulder, Colorado. Russell, K.C. (2005). Two years later: a qualitative assessment of youth well-being and the role of aftercare in outdoor behavioral healthcare treatment. Child Youth Care Forum, 34(3), 209-239. Russell, K.C. (2005). Two years later: a qualitative assessment of youth well-being and the role of aftercare in outdoor behavioral healthcare treatment. Child Youth Care Forum, 34(3), 209-239. Russell, K.C., & Harper, N. (2006). Incident monitoring in outdoor behavioral healthcare programs: a four-year summary of restraint, runaway, injury, and illness rates. Journal of Therapeutic Schools and Programs, 1(1), 70-90. Russell, K.C., & Harper, N. (2006). Incident monitoring in outdoor behavioral healthcare programs: a four-year summary of restraint, runaway, injury, and illness rates. Journal of Therapeutic Schools and Programs, 1(1), 70-90. Satcher, D. (2000). Mental health: a report of the Surgeon General. Retrieved from http://www.surgeongeneral.gov/library/mentalhealth/home.html#preface Sklar, S.L., Anderson, S.C., & Autry, C.E. (2007). Positive youth development: a wilderness intervention. Therapeutic Recreation Journal, 41(3), 223-243. Sklar, S.L., Anderson, S.C., & Autry, C.E. (2007). Positive youth development: a wilderness intervention. Therapeutic Recreation Journal, 41(3), 223-243.

42. Open Sky Research References Smollar, J., & Condelli, L. (1990). Residential placement of youth: Pathways, alternatives and unresolved issues [Electronic version]. Children Today, 19 (6), 4-8. Ungar, M., Dumond, C., & McDonald, W. (2005). Risk, resilience and out-door Ungar, M., Dumond, C., & McDonald, W. (2005). Risk, resilience and out-door programmes for at-risk children. Journal of Social Work, 5(3), 319-338. U.S. Department of Health and Human Services (1999). Mental health: A report of the Surgeon U.S. Department of Health and Human Services (1999). Mental health: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institute of Health, and National Institute of Mental Health. Wells, K. (1991). Placement of emotionally disturbed children in residential treatment: A review of placement criteria. American Journal of Orthopsychiatry, 61 (3), 339-347. Werhan, P.O. & Groff, D.G. (2005, November). Research update: The wilderness therapy trail. Werhan, P.O. & Groff, D.G. (2005, November). Research update: The wilderness therapy trail. Parks & Recreation, 24-29.

43. For more information about this study, contact: Joanna Bettmann, PhD, LCSW Open Sky Research Director joanna@openskywilderness.com 801-587-7600 www.openskywilderness.com