Bowen PhD Final Seminar 2016

Daniel BowenDoctor of Philosophy in Clinical Psychology

University of Canberra(2012 – 2016)

Adventure Therapy: Treatment Effectiveness and

Applications with Australian Youth

Primary Supervisor: Assistant Professor James NeillSecondary Supervisor: Professor Anita Mak

PhD including PublicationFinal Seminar29th July 2016

www.danielbowen.com.au/research/PhD

http://www.danielbowen.com.au/research/PhD

Presentation Overview

Context of ProjectDefinition of Adventure TherapyAims and objectives of ThesisContribution of the ThesisOverview of Studies 1-4ImplicationsStrengths and LimitationsConclusion

Context of Project

• Ensuring that young people get the best possible start in life is central to the health, social inclusion, and productivity agendas of the Australian Government

• At the forefront of a broad range of intellectual and professional agendas is the issue of what to do with ‘youth-at-risk’, and the need to protect, monitor, and sustain young people on the path to responsible adulthood

• Current evidence suggests that youth health, education and crime is an important problem within Australia

• Developing and using innovative preventative and intervention strategies which can effectively improve the health and well-being of young Australians is imperative.

Definition of Adventure Therapy(Bowen, 2016; Adapted from Pryor, 2009)

Adventure Therapy (AT) involves:

“use of small groups, nature-contact, adventure activities, and therapeutic processes to create opportunities for psychological change in participants, usually with the purpose of supporting an individual (or family) to move towards greater health and well-being.”

Aims of the Thesis

Broadly, this project aimed to: • Consolidate and advance understanding of the therapeutic uses and

treatment effectiveness of adventure therapy• Provide insight into the utility and therapeutic outcomes of Australian

AT programs for youth

Objectives: Study 1: Examine the efficacy of adventure therapy programs Study 2: Provide an up-to-date description of outdoor adventure intervention (OAI) programs and practices in Australia Study 3: Examine the efficacy of the Wilderness Adventure Therapy model of clinical treatment Study 4: Examine the efficacy of the PCYC Bornhoffen Catalyst program

Contribution of the Thesis

• A comprehensive meta-analysis of the efficacy of adventure therapy programs around the world (Study 1)

• A descriptive analysis of Australian outdoor adventure interventions (OAI) for youth based on a national survey of program managers and leaders (Study 2)

• A research evaluation of the efficacy of the Wilderness Adventure Therapy® model of clinical treatment for Australian youth (Study 3)

• A mixed methods evaluation of the efficacy of the PCYC Bornhoffen Catalyst program for Australian youth-at-risk (Study 4)

Note - Each study has an associated peer-reviewed publication which is freely and openly available

Study 1

Meta-Analysis of AT Program Outcomes and

ModeratorsPublication Status: Published

Bowen, D. J., & Neill, J. T. (2013). A meta-analysis of adventure therapy outcomes and moderators. The Open Psychology Journal, 6, 28-53. doi: 10.2174/1874350120130802001

Broadly, this study aimed to: Examine the efficacy of adventure therapy programs

internationally through a meta-analysis of outcomes and moderators– There are currently no published meta-analyses directly

concerned with adventure therapy across the life span.

Provide valuable insight regarding the utility and therapeutic outcomes of AT programs– In the 21st century, it is necessary for rigorous research to

document the effect of adventure therapy programs, and analyse the contributing factors.

• For: Boards, treatment facilities, funding bodies, policy makers and consumers.

Study 1: IntroductionMeta-Analysis of AT Program Outcomes and Moderators

Established selection criteria– AT program; reported pre/post outcomes, 1960 or later; English

Completed a comprehensive search– Identified and obtained studies were included or excluded based

on the selection criteria. Data was extracted from included studies via a Coding

Manual (Adapted from George (2011) and Wilson & Lipsey (2000))

Analysis (calculation of effect sizes) was completed using Comprehensive Meta-Analysis - Version 2

Additional comparisons were conducted to explore the existence of potential moderators

Study 1: MethodMeta-Analysis of AT Program Outcomes and Moderators

Based On: 2,908 effect sizes From 206 unique samples located within 197 studies Published between 1967 and 2012

Effect Sizes Pertain To:

Treatment Group No. & %Adventure Therapy 2,275; 78.2%

Alternative Therapy 335; 11.5%

No Therapy 298; 10.3%

Time Comparison No. & %Base-Pre 55; 1.9%

Pre-Post 2,274; 78.2%

Post-Follow-Up 579; 19.9%

Study 1: ResultsMeta-Analysis of AT Program Outcomes and Moderators

Based On: Participants: ~ 17,728 (M = 86.1; SD = 148.3 per study) Gender: male (62.5%) and female (37.5%) Age: between 9 and 64 years (M = 16.9; SD = 7.0) Program location: USA (78%), Australia (13%), Canada (3%),

Asia (3%), NZ (2%), & Europe (1%) Program Model: Ropes/Challenge/Adventure-Based (42%),

Expedition (27%), Mixed (21%), Base Camp (5%), Residential (4%), & Outpatient (1%).

Program length: 1-534 days (M = 63.5 days; SD = 148.0) Mean time b/w Base-Pre: 20.8 days (SD = 15.3) Mean time b/w Post-Follow-up: 181.4 days (SD = 276.0)


Overall Effect Sizes for Treatment Group by Time Comparison

Interpreting Effect Size: 0.20 (small), 0.50 (medium), 0.80 (large)


Comparison of Different Types of Therapy

Note: 1) As there are several noteworthy differences between adventure therapy and more traditional forms of psychotherapy, comparison of meta-analytic findings is problematic and should be interpreted with caution, and 2) as confidence intervals overlap, there are no significant differences between treatment types.

Most substantial and robust meta-analysis of adventure therapy program outcomes to date.

Confirms that overall adventure therapy is moderately effective in facilitating positive short-term change.

On average appears to be maintained in the long-term. Heterogeneity of outcomes indicates considerable

variability, although little of variance appears to be explained by the measured moderators.

Study 1: Discussion/ConclusionMeta-Analysis of AT Program Outcomes and Moderators

Study 2

Profile of OAIsFor Youth in Australia

Publication Status: PublishedBowen, D. J., Neill, J. T., Williams, I. R., Mak, A. S., Allen, N. B.,

& Olsson, C. A. (2016). A profile of outdoor adventure interventions for young people in Australia. Journal of Outdoor Recreation, Education and Leadership.

Justification: There is a lack of knowledge and understanding about

current OAI programs in Australia (Pryor, 2009)

Research Questions:1. What are the characteristics of Australian outdoor

adventure interventions for youth?2. What are the perceived outcomes and benefits from

participating in Australian outdoor adventure interventions for youth?

Study 2: IntroductionProfile of OAIs for Youth in Australia

Methodology: National data set collected by Outdoor Youth Programs

Research Alliance’s (OYPRA, 2011)– Survey collected information from program leaders (Part 1; N =

211) and managers (Part 2; N = 177) about the characteristics and qualities of outdoor programs offered to young people

Subset was selected on the basis of the main purpose or goals of the program– Programs which aimed to address problem behaviours (e.g., poor

school attendance, drug use, depression)

Subset included 98 leaders and 24 managers

Study 2: MethodProfile of OAIs for Youth in Australia

Organisational Characteristics: Programs were most often provided by:

– Not-for-profit organisations (43%), followed by school/education (17%), community (13%), government organisations (7%), business/corporate (11%), religious (6%), and health (3%)

Respondents represented organisations from all states and territories– Program managers worked for organisations in Victoria (34%), South Australia (24%), New

South Wales (12%), Queensland (12%), Tasmania (6%), Northern Territory (6%), Western Australia (3%), and the Australian Capital Territory (3%)

Staff Characteristics: Approximately two thirds of program leaders were male (63%) Approximately half of the leaders were 18 to 40 years of age (54%), about a

quarter (26%) were between 41 and 50 years, and 20% were aged 50+ Most or all field staff held relevant qualifications, including:

– Outdoor education (26%), other education/teaching (26%), outdoor recreation/instruction (24%), mental health (21%), youth work (17%), community work (7%), physical education (5%), and other (40%)

Study 2: ResultsProfile of OAIs for Youth in Australia

Program Design Characteristics: The duration of Most or All programs was:

– Less than 1 day (19%), 1 day (6%), 2 to 4 days (42%), 5 to 7 days (24%), 1 to 2 weeks (18%), and 2 weeks (29%)

Most programs were overnight journey based (57%), followed by:– Overnight hard-top programs (24%), day programs (18%), and overnight base-camp programs

(13%) The main mode of travel for journey-based programs was hiking (50%),

followed by:– Canoeing (15%), cycle touring (13%), kayaking (9%), other (9%), and rafting (4%)

The most popular activity was hiking (50%), followed by:– Continuous ropes challenge courses (37%), canoeing (30%), initiative exercises (30%),

environmental activities (28%), rappelling (23%), pioneer/bush/camp skills (23%), and giant swing/zip line (22%)

The most common theoretical frameworks featured in the program were:– Experiential learning (73%), challenge by choice (54%), facilitated reflection (52%), natural

consequence (51%), and social learning (30%)


Participant Characteristics: Ranged in age from 8 - 22 years old (Mdn = 14, M = 14.0)

Programs ranged in size from 6 - 360 participants (Mdn = 27, M = 51.3, Mode = 8)– With similar numbers of males (Mdn = 11, M = 28.5) and females (Mdn = 11, M = 21.9).

Between 1 - 46 leaders were involved in each program (Mdn = 5, M = 6.5, Mode = 2)– Including male leaders (Mdn = 3, M = 3.94) and female leaders (Mdn = 2, M = 3.24).

Programs were most often conducted with mixed-gender groups (56%)– Boys-only groups were less common (18%), and no program managers indicated that most of

their programs were for girls only

Participants were referred from:– School/education organisations (36%), community organisations (26%), government

organisations (14%), not-for-profit organisations (10%), health organisations (10%), religious organisations (2%), and businesses/corporations (2%)


Results: Prototypical group:

– Lead by a male who had worked in the sector for 10 or more years and who held a tertiary qualification

– Approximately 10 participants, co-educational, with a staff to student ratio of 1:4

Most common type of program:– Takes place over two to four days in the outdoors– Involves adventure activities (hiking, continuous ropes challenge courses,

and canoeing), – Involves group activities requiring team work, cooperation, mutual support

and communication – Involves the intentional involvement of program leaders as a basis of

learning.


Results: Surveyed staff perceived:

Program leaders believed that: The benefits lasted long-term (years) or lifelong (lasted forever).


Main Program Goals Main Program OutcomesAddressing problem behaviours Fun/enjoyment/recreation

Personal development Personal developmentSocial development Social development

Fun/enjoyment/recreation Addressing problems behaviours

Study 3

The Effectiveness of Wilderness

Adventure Therapy (WAT)Publication Status: Published

Bowen, D. J., Neill, J. T., & Crisp, S. J. R. (2016). Wilderness adventure therapy effects on the mental health of youth participants. Evaluation and Program Planning.

Study 3: IntroductionThe Effectiveness of Wilderness Adventure Therapy (WAT)

WAT®, pioneered by Dr Simon Crisp, is a theoretically designed approach using evidence-based practice

However, to date, research evaluation findings have not been formally published

Research questions:1. What is the efficacy of WAT?2. How do the effects of WAT compare to other forms of

adventure therapy?3. How do the effects of WAT compare to other forms of

therapy?

Program: Established in 1992 as a component of Australia's first clinical

adolescent day-program at the Austin Health, Child and Adolescent Mental Health Service (Vic, Australia)

Manualised, 10-week, part-time program Includes 7 day-based adventure activities (e.g., bushwalking,

abseiling, cross country skiing, & white water rafting) Includes 2 & 5 day outdoor expeditions Parents, teachers and support workers participate in 8 AT-

based sessions Follow-up includes liaison with other agencies, group re-union,

and school or placement outreach follow-up

Study 3: IntroductionThe Effectiveness of Wilderness Adventure Therapy (WAT)

Participants: Completed 1 of 8 WAT interventions in 2000 and 2001 36 adolescents:

– 21 females & 15 males– Aged between 12-18 years (M = 14.6)

Self-report data collected: – pre-program, post-program and at three-month follow-up

Measures Included:

Study 3: MethodThe Effectiveness of Wilderness Adventure Therapy (WAT)

Resilience Questionnaire Beck Depression Inventory Youth Self Report

Coopersmith Self Esteem Inventory C.O.R.E Family Functioning Questionnaire Life Attitudes Schedule

Study 3: ResultsThe Effectiveness of Wilderness Adventure Therapy (WAT)

Short- & Longer-Term Effect Sizes for All Participants (n = 36)

* indicates ES is statistically significant. An increase signifies improvementNote. All Short-term ES are within aged-based AT meta-analytic benchmarks, except Suicidal-Proneness which is lower than expected

Outcome ES % Change ES % Change

Resilience 0.49* 24 -0.30 15

Depression 0.46* 22 0.00 0

Behavioural & Emotional Functioning 0.36 18 0.03 2

Self-Esteem 0.26 13 0.06 3

Overall 0.26* 13 -0.06 3

Family Functioning 0.12 6 -0.58* 28

Suicidal-Proneness -0.06 3 0.43* 21


Statistically Significant Short-Term Effect Sizes & AT Meta-Analytic Benchmarks for all Participants (n = 36)


Statistically Significant Short-Term Effect Sizes

& AT Meta-Analytic

Benchmarks for Clinical Range Participants


Depressive Symptoms for Participants in the Clinical (n = 23) and Non-Clinical (n = 13) Range Before Treatment


YSR Means for Most Severe Mental Health Symptom for Participants Before Treatment (n = 36)

Discussion/Conclusion: The overall short-term effect size was small, positive, and statistically

significant (0.26) For the most part, short-term changes were retained at a three-month

follow-up Most of the short-term effects were within the age-based meta-analytic

adventure therapy benchmarks Participants in clinical symptom range pre-program reported large to very

large, statistically significant improvements Findings suggest some promise that WAT interventions may offer a viable

alternative treatment modality to more traditional psychotherapeutic approaches for youth at-risk

More in-depth investigation would help to better understand what works and what could be improved

Study 3: Discussion/ConclusionThe Effectiveness of Wilderness Adventure Therapy (WAT)

Study 4

The Effectiveness of the PCYC Catalyst Program

Publication Status: PublishedBowen, D. J., & Neill, J. T. (2015). Effects of the PCYC Catalyst

outdoor adventure intervention program on youths’ life skills, mental health, and delinquent behaviour. International Journal of Adolescence and Youth, 1-22. doi: 10.1080/02673843.2015.102771

Study 4: IntroductionThe Effectiveness of the PCYC Catalyst Program

(PCYC Bornhoffen Adventure Development, 2011)

PCYC Bornhoffen Catalyst Program: An AT program operated by PCYC in QLD between 2012 and 2013,

funded via state-based Blue Light and Proceeds of Crime Funds– Targeting: Personal and social development, within the context of reducing crime

For young people (aged 11 to 14 years) ‘at risk’ of adverse outcomes in their educational, vocational and life-course pathways

Involves a 3 day lead-in, a 9 day expedition, and a 3 day follow-up (with gaps in-between each section)

Research questions: What is the efficacy of the Catalyst program? How do the effects of the Catalyst program compare to other forms of

adventure therapy? How do the effects of the Catalyst compare to other forms of

therapy?

Participants:• 6 Catalyst programs completed by 53 youth

Methodology & Analysis:• Quantitative: Self-Report Measures

o Collected pre- and post-program (N = 36), 6-12 month follow-up (N = 29) o Youth at Risk Program Evaluation Tool; General Well-Being; Adolescent

Behavioural Conducto Short- (T1 to T2) and longer-term (T2 to T3) changes were investigated using

descriptive statistics, and mean effect sizes with 95% confidence intervals.o Results were compared to meta-analytic benchmarks from Bowen & Neill (2013)

• Qualitative: Semi-Structured Interviewso Semi-structured interviews were completed with 14 youth participantso Analysed using inductive thematic analysis (Braun & Clarke, 2006)

Study 4: MethodThe Effectiveness of the PCYC Catalyst Program

Longer-term ES for Life Effectiveness (n = 29)

Study 4: Quantitative ResultsThe Effectiveness of the PCYC Catalyst Program

Longer-term ES for Mental Health (n = 28)


Longer-term ES for Behavioural Conduct (n = 27)


Six major themes were identified:

Study 4: Qualitative ResultsThe Effectiveness of the PCYC Catalyst Program

Pattern Codes Descriptive CodesOvercoming challenging backgrounds

Extreme circumstances; Multiple risk factors

Contending with adversity Distress, Crisis, Difficulty, Challenge, ConflictPersonal development Resilience, Self-belief, Self-confidence, Self-

control, Self-esteemSocial development Social skills, Communication, Cooperative

Teamwork, RelationshipsMotivation to work for change Try harder, have a go, Make an effortMore optimistic outlook on the future

New beginnings, Goal setting, Hope

Participants reported:– Small positive changes in life effectiveness, – A large long-term improvement in psychological well-being,– Some improvements in particular aspects of delinquent behaviour (e.g., Harming,

Fighting, Stealing, and Vandalism),– No positive longer-term impact on psychological distress and some aspects of

behaviour Six major themes emerged from interviews with youth participants:

– Overcoming challenging backgrounds, contending with adversity, personal development, social development, motivation to work for change, and optimistic future outlook

Quantitative and qualitative results support the conclusion that this program may offer a viable alternative or adjunct treatment approach to more traditional psychotherapeutic approaches for youth at-risk

More in-depth investigation would help to better understand what works and what could be improved

Study 4: Discussion/ConclusionThe Effectiveness of the PCYC Catalyst Program

Thesis: Practice Implications

• AT meta-analytic findings can be used in benchmarking and monitoring program effectiveness (Study 1)

• Participant age was the only significant moderator of adventure therapy programs, with stronger outcomes for older participants (Study 1)

• Despite diversity in approach, the OAI profile depicts an approach for working with youth that provides an environment of change through use of small groups, contact with nature, adventure activities, and therapeutic processes (Study 2)

• The use of AT to address psychological, behavioural, emotional, and interpersonal problems for youth in Australia could be improved (effects were below the international benchmark) (Study 1, 3, and 4)

• WAT is as effective as traditional psychotherapy techniques for clinically symptomatic youth (Study 3)

• The PCYC Bornhoffen Catalyst program offers a potentially viable alternative treatment modality to more traditional psychotherapeutic approaches for youth at-risk (Study 4)

Thesis: Research Implications

• A more targeted survey is required to develop a comprehensive profile of adventure therapy programming in Australia

• More in-depth and methodologically rigorous program evaluation with larger samples sizes is required to understand the effectiveness of adventure-based interventions and increase generalisability

• Multiple imputation and maximum likelihood are recommended to handle missing data in future adventure therapy research

• Future adventure therapy research should consider focusing on the clinical application of findings (rather than statistical significance)

• There is a need for future mixed method research to extend understanding of adventure therapy processes and outcomes

• There is a need for future research to consider the cost-effectiveness of AT as compared to alternative treatments

Thesis: Strengths

• Addressed several major limitations of prior related meta-analyses, compared outcomes with alternative and no treatment groups, and employed additional meta-analytic analysis techniques (publication bias, meta-regression, moderator analyses) (Study 1)

• Provided an up-to-date profile of Australian outdoor adventure intervention programs for youth (Study 2)

• Used multiple imputation, a ‘state of the art’ technique, to deal with missing data (Study 3)

• In addition to considering statistical significance, client change was also reported in terms of clinical significance (Study 3)

• Completed a mixed method investigation of an Australian outdoor adventure intervention (Study 4)

Thesis: Limitations

• Exclusively relied on participant self-report data (Studies 1-4)

• Study 2 was based on a subset of data which was collected to establish a profile of Australian outdoor youth programs

• Lack of random assignment to treatment conditions and the absence of a comparison group (Studies 3 & 4)

• Generalisability due to adventure therapy programs differing significantly (finding from Study 1 and 2)

• Generalisability due to small sample size (Studies 3 & 4)

• Study 3 utilised two non-validated questionnaires

Conclusion

• While adventure therapy is not a panacea, findings from this thesis confirm that adventure therapy has broad application for adolescents and adults for a wide range of presenting issues

• This thesis provides good evidence that adventure therapy programs provide social, behavioural and psychological benefits for participants which are comparable to the majority of efficacious treatments for patients across the age span reported in the literature

• Findings from this thesis strongly support the inclusion of adventure therapy as part of the suite of therapeutic interventions that operate in diverse service settings across Australia

Thanks for your time!

Questions / Feedback?

Daniel Bowenwww.danielbowen.com.au/research/PhD

[email protected]@danielbowen.com.au

http://www.danielbowen.com.au/research/PhD

mailto:[email protected]

mailto:[email protected]

Bowen PhD Final Seminar 2016

Healthcare

Transcript of Bowen PhD Final Seminar 2016