Background: Adventure therapy (AT) is a term that includes therapies such as wilderness therapy and adventure-based counseling. With growing empirical support for AT, the diversity of studies make it difficult to attribute outcomes to specific treatment factors.
Objectives: Researchers explored whether AT, often perceived as an alternative therapy, works because of AT's unique components, or whether factors shared by all therapies were responsible.
Methods: A scoping review was undertaken utilizing a search of major databases, unpublished disser- tations, and a hand search for direct comparison trials matching AT with another therapeutic intervention.
Results: 881 publications were identified. 105 quantitative studies were included following a title and abstract review. Only 13 met the full inclusion criteria. Little to no differences were found to isolate specific therapeutic factors.
Conclusions: We discuss the implications of these results considering the movement toward evidence- based practice and recommend future research to eclipse our current understanding of AT.
Evidence-Based Treatments and Integrative PsychotherapyKevin Rushton
The document discusses reactions to the "Dodo bird verdict" which suggests that all major psychotherapies are equally effective. Researchers have tried to disprove this through efficacy research to identify superior therapies, while practitioners have embraced integration by combining different approaches. The document also examines criticisms of efficacy research methodology and the rise of psychotherapy integration among practitioners.
This document provides a critique of 4 recent meta-analyses published in Health Psychology. It finds problems with transparency and completeness in how the meta-analyses were reported. It also notes a dependence on small, underpowered original trials of generally poor quality. The document questions the clinical validity and utility of conclusions drawn from these meta-analyses due to issues like clinical heterogeneity among studies and lack of consideration of methodological quality. Overall, it aims to encourage more rigorous standards for meta-analyses to avoid inaccurate or exaggerated conclusions.
This document summarizes a meta-analysis of 206 studies on adventure therapy outcomes published between 1967 and 2012. The meta-analysis found that adventure therapy has a moderate positive effect on psychosocial outcomes, with an overall effect size of 0.50 for pre-post outcomes. Larger effects were found for outcomes related to self-concept, social development, and clinical measures. Moderator analyses found slightly larger effects for older participants and programs with an open group structure. The meta-analysis provides benchmarking data to evaluate adventure therapy program outcomes.
This document summarizes a simulation study comparing the performance of different meta-analysis methods when assumptions of normality are violated. The study generated simulated datasets with various distributions for true effects and degrees of heterogeneity. It then compared methods like fixed effects, DerSimonian-Laird, maximum likelihood, and permutations in terms of coverage, power, and confidence interval estimation. The results showed that some methods are more robust to non-normal data, with profile likelihood and permutations generally performing best, while other methods like fixed effects and DerSimonian-Laird showed poorer performance.
Comparative efficacy and acceptability of 21 antidepressant drugs, powerpoint...Shamim Rahman
This document summarizes a systematic review and network meta-analysis that compared the efficacy and tolerability of 21 antidepressant drugs for treating major depressive disorder in adults. The analysis included data from 522 randomized controlled trials with over 116,000 participants. The results showed that while all antidepressants were more effective than placebo, some drugs like escitalopram, mirtazapine, and sertraline tended to have higher response rates and lower dropout rates than other options. Reboxetine, trazodone, and fluvoxamine generally had inferior efficacy and tolerability profiles. There were few differences between antidepressants when considering all data, but head-to-head trials showed more variability in effects.
Imran rizvi statistics in meta analysisImran Rizvi
This document discusses statistics used in meta-analyses. It explains that meta-analyses statistically combine results from multiple studies on a topic. Effect measures are calculated for individual studies and then combined to find an overall effect. For dichotomous outcomes, common effect measures are risk ratio, odds ratio, and absolute risk reduction. Random effects models account for heterogeneity between studies, while fixed effect models assume one true effect. Forest plots visually display individual study results and the overall effect, allowing readers to assess consistency and precision.
Evidence-Based Treatments and Integrative PsychotherapyKevin Rushton
The document discusses reactions to the "Dodo bird verdict" which suggests that all major psychotherapies are equally effective. Researchers have tried to disprove this through efficacy research to identify superior therapies, while practitioners have embraced integration by combining different approaches. The document also examines criticisms of efficacy research methodology and the rise of psychotherapy integration among practitioners.
This document provides a critique of 4 recent meta-analyses published in Health Psychology. It finds problems with transparency and completeness in how the meta-analyses were reported. It also notes a dependence on small, underpowered original trials of generally poor quality. The document questions the clinical validity and utility of conclusions drawn from these meta-analyses due to issues like clinical heterogeneity among studies and lack of consideration of methodological quality. Overall, it aims to encourage more rigorous standards for meta-analyses to avoid inaccurate or exaggerated conclusions.
This document summarizes a meta-analysis of 206 studies on adventure therapy outcomes published between 1967 and 2012. The meta-analysis found that adventure therapy has a moderate positive effect on psychosocial outcomes, with an overall effect size of 0.50 for pre-post outcomes. Larger effects were found for outcomes related to self-concept, social development, and clinical measures. Moderator analyses found slightly larger effects for older participants and programs with an open group structure. The meta-analysis provides benchmarking data to evaluate adventure therapy program outcomes.
This document summarizes a simulation study comparing the performance of different meta-analysis methods when assumptions of normality are violated. The study generated simulated datasets with various distributions for true effects and degrees of heterogeneity. It then compared methods like fixed effects, DerSimonian-Laird, maximum likelihood, and permutations in terms of coverage, power, and confidence interval estimation. The results showed that some methods are more robust to non-normal data, with profile likelihood and permutations generally performing best, while other methods like fixed effects and DerSimonian-Laird showed poorer performance.
Comparative efficacy and acceptability of 21 antidepressant drugs, powerpoint...Shamim Rahman
This document summarizes a systematic review and network meta-analysis that compared the efficacy and tolerability of 21 antidepressant drugs for treating major depressive disorder in adults. The analysis included data from 522 randomized controlled trials with over 116,000 participants. The results showed that while all antidepressants were more effective than placebo, some drugs like escitalopram, mirtazapine, and sertraline tended to have higher response rates and lower dropout rates than other options. Reboxetine, trazodone, and fluvoxamine generally had inferior efficacy and tolerability profiles. There were few differences between antidepressants when considering all data, but head-to-head trials showed more variability in effects.
Imran rizvi statistics in meta analysisImran Rizvi
This document discusses statistics used in meta-analyses. It explains that meta-analyses statistically combine results from multiple studies on a topic. Effect measures are calculated for individual studies and then combined to find an overall effect. For dichotomous outcomes, common effect measures are risk ratio, odds ratio, and absolute risk reduction. Random effects models account for heterogeneity between studies, while fixed effect models assume one true effect. Forest plots visually display individual study results and the overall effect, allowing readers to assess consistency and precision.
Feedback informed treatment (fit) achieving(apa ip miller hubble seidel chow ...Scott Miller
1) The document discusses Feedback Informed Treatment (FIT), which uses routine monitoring of a client's progress and the therapeutic alliance to improve outcomes. Short scales like the Session Rating Scale and Outcome Rating Scale are used to gather feedback from clients.
2) Research shows that formal collection and discussion of client feedback doubles rates of reliable change, decreases dropout rates by 50%, and cuts deterioration rates by a third compared to treatment without feedback.
3) The feedback allows therapists to adjust their approach if a client is not progressing well or the alliance is weakening, in order to maximize the fit between client, therapist, and treatment for that individual.
The document summarizes a systematic review of 23 randomized controlled trials that examined the efficacy of distant healing, which includes prayer, Therapeutic Touch, and other forms of spiritual healing. The trials involved a total of 2774 patients. 13 of the trials, representing 57% of studies, found statistically significant treatment effects of distant healing. While methodological limitations make definitive conclusions difficult, the authors found that given over half of trials showed benefits, further research is warranted.
This document outlines the steps involved in conducting a systematic review and meta-analysis on the prevalence of elder abuse. It discusses how 52 studies from around the world were analyzed using comprehensive meta-analysis software. The key findings were that the pooled prevalence of elder abuse was 15.7%. While systematic reviews have strengths like being comprehensive and transparent, they also have limitations such as reliance on the quality of primary studies and risk of publication bias.
The randomized controlled trial is considered the most rigorous method for determining whether a causal relationship exists between an intervention and outcome. Participants are randomly assigned to either the experimental group receiving the intervention being tested, or the control group receiving an alternative or placebo treatment. Randomization aims to ensure any differences in outcomes are due to the treatments alone rather than other factors, by making the groups similar in all respects except for the intervention. Common randomization methods include simple, block, and stratified randomization. Blinding of participants and investigators is also important to minimize bias when assessing outcomes.
Title:
Adventure Therapy: Treatment Effectiveness and Applications with Australian Youth
Abstract:
This final seminar reviews the original contribution of Bowen’s (2016) PhD thesis to the field of adventure therapy. This thesis advances understanding of the therapeutic uses and treatment effectiveness of adventure therapy by systematically reviewing the efficacy of adventure therapy programs internationally (Study 1), providing an up-to-date profile of Australian outdoor adventure intervention programs for youth (Study 2), examining the efficacy of the Wilderness Adventure Therapy® model of clinical treatment for Australian youth (Study 3), and examining the efficacy of the PCYC Bornhoffen Catalyst program for Australian youth-at-risk (Study 4). Findings from this thesis strongly support the assertion that adventure therapy should be in the suite of therapeutic interventions that operate in diverse service settings across Australia. For more information, see http://www.danielbowen.com.au/research/PhD
Primary supervisor: Assistant Professor James Neill
Supervisory panel member: Professor Anita Mak
This document describes the development and validation of a clinical knowledge measurement tool to assess community pharmacists' ability to detect and resolve drug-related problems (DRPs). The tool consists of 9 clinical cases with multiple choice questions. It was administered to pharmacy students and community pharmacists in Australia. The tool showed good internal consistency and differentiated knowledge levels between student year groups as expected. Pharmacists' scores also correlated with their actual rate of documenting clinical interventions in practice, indicating the tool is effective at estimating pharmacists' ability to detect and resolve DRPs.
1) Meta-analysis is a statistical technique that combines the results of multiple studies on a topic and produces a single estimate of the overall effect. It aims to increase power by pooling data.
2) The first meta-analysis was conducted in 1904, and the term was coined in 1976. Meta-analysis is now often called a "systematic review."
3) Meta-analysis can help clinicians and policymakers integrate research findings and determine if relationships are consistent across studies. It increases precision and statistical power compared to individual studies.
Six studies with a total of 340 participants were included in a meta-analysis examining the effect of ondansetron on the efficacy of postoperative tramadol. The meta-analysis found that patients receiving ondansetron required significantly higher doses of tramadol at 4, 8, 12, and 24 hours postoperatively compared to those receiving tramadol alone. Additionally, there was a significant linear decline in the effect of ondansetron over time, indicating that the drug interaction between tramadol and ondansetron diminished after 24 hours. The results support the presence of a drug interaction between tramadol and ondansetron in the early postoperative period that decreases the effectiveness of tramadol.
This document discusses meta-analysis techniques for systematically reviewing and statistically combining results from multiple clinical trials. It covers the history of meta-analysis, methodology for combining test statistics and assessing heterogeneity, software for conducting meta-analyses, and current issues including how to handle different study designs. Examples are provided to illustrate meta-analysis of randomized controlled trials comparing treatments for stroke, myocardial infarction, and other conditions.
This document discusses different methods of randomization used in clinical trials. It defines randomization as assigning participants equally to treatment groups to provide unbiased estimates. The key methods discussed are:
1. Simple randomization, which uses chance like coin flips but can lead to imbalance in small trials.
2. Permuted block randomization, which uses blocks of predetermined assignments to balance groups over time.
3. Stratified randomization, which balances covariates between groups by assigning participants to blocks based on covariate levels before random assignment.
4. Covariant adaptive randomization, which sequentially assigns participants by taking into account covariates and previous assignments to balance groups.
Expanding the Lens of EBP: A Common Factors in AgreementScott Miller
The authors explore the limitations of the traditional view of evidence-based practice with its emphasis on specific methods and diagnosis. An alternative is proposed based on the common factors.
This document discusses different types and aspects of randomized controlled trials (RCTs). It begins by classifying RCTs into parallel group, crossover, split-body, cluster, and factorial designs based on how subjects are assigned to groups. It then discusses classification by outcome measured (efficacy vs effectiveness) and hypothesis tested (superiority vs noninferiority vs equivalence). The document goes on to cover randomization methods, including advantages of proper randomization and restricted randomization techniques. It also discusses allocation concealment, blinding, analysis of RCT data, reporting standards, advantages and limitations of RCTs, and other topics relevant to RCT design and interpretation.
This study examined the effects of using client feedback, known as the Partners for Change Outcome Management System (PCOMS), with couples undergoing psychotherapy. 46 heterosexual couples were randomly assigned to either a treatment as usual (TAU) condition or to a feedback condition where therapists received feedback on client progress and the therapeutic alliance at each session via the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). It was hypothesized that couples receiving feedback would have better outcomes, improve more quickly, and be more likely to meet the criteria for clinically significant change. Results from this study aimed to replicate previous research finding client feedback beneficial for couples therapy.
The document discusses techniques used in clinical trial design such as randomization, blinding, and study design. Randomization techniques include simple, restricted, stratified, and adaptive randomization to control for bias and variability. Blinding (single, double, triple) aims to eliminate subjective bias by withholding treatment information from patients and investigators. Study design determines objectives and compares new treatments parallel to current treatments through randomized parallel group designs. Proper selection and randomization of patients represents the target population.
Rationale and Standards of Evidence in Evidence-Based Practice.docxmakdul
Rationale and Standards of Evidence in Evidence-Based Practice
OLIVER C. MUDFORD, ROB MCNEILL, LISA WALTON
AND KATRINA J. PHILLIPS
What is the purpose of collecting evidence to inform clinical practice in psychology concerning the effects of psychological or other interventions? To quote Paul’s (1967) article that has been cited 330 times before November 4, 2008, it is to determine the answer to the question: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances?” (p. 111). Another answer is pitched at a systemic level, rather than concerning individuals. That is, research evidence can inform health-care professionals and consumers about psychological and behavioral interventions that are more effective than pharmacological treatments, and to improve the overall quality and cost-effectiveness of psychological health service provision (American Psychological Association [APA] Presidential Task Force on Evidence-Based Practice, 2006). The most general answer is that research evidence can be used to improve outcomes for clients, service providers, and society in general. The debate about what counts as evidence of effectiveness in answering this question has attracted considerable controversy (Goodheart, Kazdin, & Sternberg, 2006; Norcross, Beutler, & Levant, 2005). At one end of a spectrum, evidence from research on psychological treatments can be emphasized. Research-oriented psychologists have promoted the importance of scientific evidence in the concept of empirically supported treatment. Empirically supported treatments (ESTs) are those that have been sufficiently subjected to scientific research and have been shown to produce beneficial effects in wellcontrolled studies (i.e., efficacious), in more natural clinical environments (i.e., effective), and are the most cost-effective (i.e., efficient) (Chambless & Hollon, 1998). The effective and efficient criteria of Chambless and Hollon (1998) have been amalgamated under the term “clinical utility” (APA Presidential Task Force on Evidence-Based Practice, 2006; Barlow, Levitt, & Bufka, 1999). At the other end of the spectrum are psychologists who value clinical expertise as the source of evidence more highly, and they can rate subjective impressions and skills acquired in practice as providing personal evidence for guiding treatment (Hunsberger, 2007). Kazdin (2008) has asserted that the schism between clinical researchers and practitioners on the issue of evidence is deepening. Part of the problem, which suggests at least part of the solution, is that research had concentrated on empirical evidence of treatment efficacy, but more needs c01 20 April 2012; 12:43:29 3 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID= ...
Running head RESEARCH PROPOSAL ON COUPLES COUNSELING RESEA.docxtoltonkendal
This document discusses different therapy methods for couples, including individual therapy, group therapy, and couples therapy. It reviews past research comparing the effectiveness of these different methods. The document proposes conducting a new study that would survey couples who have undergone individual therapy, group therapy, or couples therapy. The study would administer a questionnaire to determine which therapy method was most effective for the couples. The goal is to identify the best approach for helping couples overcome relationship issues like rejection from family members regarding their sexual orientation.
Feedback informed treatment (fit) achieving(apa ip miller hubble seidel chow ...Scott Miller
1) The document discusses Feedback Informed Treatment (FIT), which uses routine monitoring of a client's progress and the therapeutic alliance to improve outcomes. Short scales like the Session Rating Scale and Outcome Rating Scale are used to gather feedback from clients.
2) Research shows that formal collection and discussion of client feedback doubles rates of reliable change, decreases dropout rates by 50%, and cuts deterioration rates by a third compared to treatment without feedback.
3) The feedback allows therapists to adjust their approach if a client is not progressing well or the alliance is weakening, in order to maximize the fit between client, therapist, and treatment for that individual.
The document summarizes a systematic review of 23 randomized controlled trials that examined the efficacy of distant healing, which includes prayer, Therapeutic Touch, and other forms of spiritual healing. The trials involved a total of 2774 patients. 13 of the trials, representing 57% of studies, found statistically significant treatment effects of distant healing. While methodological limitations make definitive conclusions difficult, the authors found that given over half of trials showed benefits, further research is warranted.
This document outlines the steps involved in conducting a systematic review and meta-analysis on the prevalence of elder abuse. It discusses how 52 studies from around the world were analyzed using comprehensive meta-analysis software. The key findings were that the pooled prevalence of elder abuse was 15.7%. While systematic reviews have strengths like being comprehensive and transparent, they also have limitations such as reliance on the quality of primary studies and risk of publication bias.
The randomized controlled trial is considered the most rigorous method for determining whether a causal relationship exists between an intervention and outcome. Participants are randomly assigned to either the experimental group receiving the intervention being tested, or the control group receiving an alternative or placebo treatment. Randomization aims to ensure any differences in outcomes are due to the treatments alone rather than other factors, by making the groups similar in all respects except for the intervention. Common randomization methods include simple, block, and stratified randomization. Blinding of participants and investigators is also important to minimize bias when assessing outcomes.
Title:
Adventure Therapy: Treatment Effectiveness and Applications with Australian Youth
Abstract:
This final seminar reviews the original contribution of Bowen’s (2016) PhD thesis to the field of adventure therapy. This thesis advances understanding of the therapeutic uses and treatment effectiveness of adventure therapy by systematically reviewing the efficacy of adventure therapy programs internationally (Study 1), providing an up-to-date profile of Australian outdoor adventure intervention programs for youth (Study 2), examining the efficacy of the Wilderness Adventure Therapy® model of clinical treatment for Australian youth (Study 3), and examining the efficacy of the PCYC Bornhoffen Catalyst program for Australian youth-at-risk (Study 4). Findings from this thesis strongly support the assertion that adventure therapy should be in the suite of therapeutic interventions that operate in diverse service settings across Australia. For more information, see http://www.danielbowen.com.au/research/PhD
Primary supervisor: Assistant Professor James Neill
Supervisory panel member: Professor Anita Mak
This document describes the development and validation of a clinical knowledge measurement tool to assess community pharmacists' ability to detect and resolve drug-related problems (DRPs). The tool consists of 9 clinical cases with multiple choice questions. It was administered to pharmacy students and community pharmacists in Australia. The tool showed good internal consistency and differentiated knowledge levels between student year groups as expected. Pharmacists' scores also correlated with their actual rate of documenting clinical interventions in practice, indicating the tool is effective at estimating pharmacists' ability to detect and resolve DRPs.
1) Meta-analysis is a statistical technique that combines the results of multiple studies on a topic and produces a single estimate of the overall effect. It aims to increase power by pooling data.
2) The first meta-analysis was conducted in 1904, and the term was coined in 1976. Meta-analysis is now often called a "systematic review."
3) Meta-analysis can help clinicians and policymakers integrate research findings and determine if relationships are consistent across studies. It increases precision and statistical power compared to individual studies.
Six studies with a total of 340 participants were included in a meta-analysis examining the effect of ondansetron on the efficacy of postoperative tramadol. The meta-analysis found that patients receiving ondansetron required significantly higher doses of tramadol at 4, 8, 12, and 24 hours postoperatively compared to those receiving tramadol alone. Additionally, there was a significant linear decline in the effect of ondansetron over time, indicating that the drug interaction between tramadol and ondansetron diminished after 24 hours. The results support the presence of a drug interaction between tramadol and ondansetron in the early postoperative period that decreases the effectiveness of tramadol.
This document discusses meta-analysis techniques for systematically reviewing and statistically combining results from multiple clinical trials. It covers the history of meta-analysis, methodology for combining test statistics and assessing heterogeneity, software for conducting meta-analyses, and current issues including how to handle different study designs. Examples are provided to illustrate meta-analysis of randomized controlled trials comparing treatments for stroke, myocardial infarction, and other conditions.
This document discusses different methods of randomization used in clinical trials. It defines randomization as assigning participants equally to treatment groups to provide unbiased estimates. The key methods discussed are:
1. Simple randomization, which uses chance like coin flips but can lead to imbalance in small trials.
2. Permuted block randomization, which uses blocks of predetermined assignments to balance groups over time.
3. Stratified randomization, which balances covariates between groups by assigning participants to blocks based on covariate levels before random assignment.
4. Covariant adaptive randomization, which sequentially assigns participants by taking into account covariates and previous assignments to balance groups.
Expanding the Lens of EBP: A Common Factors in AgreementScott Miller
The authors explore the limitations of the traditional view of evidence-based practice with its emphasis on specific methods and diagnosis. An alternative is proposed based on the common factors.
This document discusses different types and aspects of randomized controlled trials (RCTs). It begins by classifying RCTs into parallel group, crossover, split-body, cluster, and factorial designs based on how subjects are assigned to groups. It then discusses classification by outcome measured (efficacy vs effectiveness) and hypothesis tested (superiority vs noninferiority vs equivalence). The document goes on to cover randomization methods, including advantages of proper randomization and restricted randomization techniques. It also discusses allocation concealment, blinding, analysis of RCT data, reporting standards, advantages and limitations of RCTs, and other topics relevant to RCT design and interpretation.
This study examined the effects of using client feedback, known as the Partners for Change Outcome Management System (PCOMS), with couples undergoing psychotherapy. 46 heterosexual couples were randomly assigned to either a treatment as usual (TAU) condition or to a feedback condition where therapists received feedback on client progress and the therapeutic alliance at each session via the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). It was hypothesized that couples receiving feedback would have better outcomes, improve more quickly, and be more likely to meet the criteria for clinically significant change. Results from this study aimed to replicate previous research finding client feedback beneficial for couples therapy.
The document discusses techniques used in clinical trial design such as randomization, blinding, and study design. Randomization techniques include simple, restricted, stratified, and adaptive randomization to control for bias and variability. Blinding (single, double, triple) aims to eliminate subjective bias by withholding treatment information from patients and investigators. Study design determines objectives and compares new treatments parallel to current treatments through randomized parallel group designs. Proper selection and randomization of patients represents the target population.
Rationale and Standards of Evidence in Evidence-Based Practice.docxmakdul
Rationale and Standards of Evidence in Evidence-Based Practice
OLIVER C. MUDFORD, ROB MCNEILL, LISA WALTON
AND KATRINA J. PHILLIPS
What is the purpose of collecting evidence to inform clinical practice in psychology concerning the effects of psychological or other interventions? To quote Paul’s (1967) article that has been cited 330 times before November 4, 2008, it is to determine the answer to the question: “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances?” (p. 111). Another answer is pitched at a systemic level, rather than concerning individuals. That is, research evidence can inform health-care professionals and consumers about psychological and behavioral interventions that are more effective than pharmacological treatments, and to improve the overall quality and cost-effectiveness of psychological health service provision (American Psychological Association [APA] Presidential Task Force on Evidence-Based Practice, 2006). The most general answer is that research evidence can be used to improve outcomes for clients, service providers, and society in general. The debate about what counts as evidence of effectiveness in answering this question has attracted considerable controversy (Goodheart, Kazdin, & Sternberg, 2006; Norcross, Beutler, & Levant, 2005). At one end of a spectrum, evidence from research on psychological treatments can be emphasized. Research-oriented psychologists have promoted the importance of scientific evidence in the concept of empirically supported treatment. Empirically supported treatments (ESTs) are those that have been sufficiently subjected to scientific research and have been shown to produce beneficial effects in wellcontrolled studies (i.e., efficacious), in more natural clinical environments (i.e., effective), and are the most cost-effective (i.e., efficient) (Chambless & Hollon, 1998). The effective and efficient criteria of Chambless and Hollon (1998) have been amalgamated under the term “clinical utility” (APA Presidential Task Force on Evidence-Based Practice, 2006; Barlow, Levitt, & Bufka, 1999). At the other end of the spectrum are psychologists who value clinical expertise as the source of evidence more highly, and they can rate subjective impressions and skills acquired in practice as providing personal evidence for guiding treatment (Hunsberger, 2007). Kazdin (2008) has asserted that the schism between clinical researchers and practitioners on the issue of evidence is deepening. Part of the problem, which suggests at least part of the solution, is that research had concentrated on empirical evidence of treatment efficacy, but more needs c01 20 April 2012; 12:43:29 3 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology, Child and Adolescent Disorders, John Wiley & Sons, Incorporated, 2012. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID= ...
Running head RESEARCH PROPOSAL ON COUPLES COUNSELING RESEA.docxtoltonkendal
This document discusses different therapy methods for couples, including individual therapy, group therapy, and couples therapy. It reviews past research comparing the effectiveness of these different methods. The document proposes conducting a new study that would survey couples who have undergone individual therapy, group therapy, or couples therapy. The study would administer a questionnaire to determine which therapy method was most effective for the couples. The goal is to identify the best approach for helping couples overcome relationship issues like rejection from family members regarding their sexual orientation.
1. Researchers evaluate the effectiveness of therapies through methods like meta-analyses of existing studies to identify the most effective treatments for issues like depression. Common factors like the therapeutic relationship contribute to positive outcomes.
2. While therapies like CBT are supported as effective, researchers still do not fully understand why they work. Prevention strategies aim to reduce mental illness at the primary, secondary, and tertiary levels through skills training, early identification and treatment, and relapse prevention.
3. Evaluating therapeutic effectiveness and identifying common success factors helps improve treatments, while prevention research works to reduce mental illness occurrence and severity.
Model of TreatmentEducation and its EvaluationProblem.docxhelzerpatrina
Model of Treatment/Education and its Evaluation
Problem(s)
Will Power +
Common Factors +
Any Specific Factor (any treatment model EBP or other) +
Feedback Informed Treatment + Deliberate Practice =
Effective Outcome
SPECIAL ARTICLE
How important are the common factors in
psychotherapy? An update
BRUCE E. WAMPOLD
Department of Counseling Psychology, University of Wisconsin, Madison, WI, USA; Modum Bad Psychiatric Center, Vikersund, Norway
The common factors have a long history in the field of psychotherapy theory, research and practice. To understand the evidence supporting
them as important therapeutic elements, the contextual model of psychotherapy is outlined. Then the evidence, primarily from meta-
analyses, is presented for particular common factors, including alliance, empathy, expectations, cultural adaptation, and therapist differ-
ences. Then the evidence for four factors related to specificity, including treatment differences, specific ingredients, adherence, and compe-
tence, is presented. The evidence supports the conclusion that the common factors are important for producing the benefits of psychotherapy.
Key words: Common factors, contextual model, psychotherapy, alliance, empathy, expectations, cultural adaptation, therapist differences,
specific ingredients
(World Psychiatry 2015;14:270–277)
The so-called common factors have a long history in psy-
chiatry, originating with a seminal article by S. Rosenzweig
in 1936 (1) and popularized by J. Frank in the various
editions of his book Persuasion and Healing (2-4). During
this period, the common factors have been both embraced
and dismissed, creating some tension (5-9). The purpose of
this paper is not to review or discuss the debate, but to pro-
vide an update, summarizing the evidence related to these
factors.
To understand the evidence for the common factors, it is
important to keep in mind that these factors are more than a
set of therapeutic elements that are common to all or most
psychotherapies. They collectively shape a theoretical mod-
el about the mechanisms of change in psychotherapy.
A particular common factor model, called the contextual
model, has been recently proposed (8,10). Although there
are other common factor models (e.g., 4,11), based on differ-
ent theoretical propositions, the predictions made about the
importance of various common factors are similar and the
choice of the model does not affect conclusions about the
impact of these factors. The contextual model is presented
below, followed by a review of the evidence for the common
factors imbedded in the model.
THE CONTEXTUAL MODEL
The contextual model posits that there are three path-
ways through which psychotherapy produces benefits. That
is, psychotherapy does not have a unitary influence on
patients, but rather works through various mechanisms.
The mechanisms underlying the three pathways entail
evolved characteristics of humans as the ultimate social spe-
cies; as such.
Model of TreatmentEducation and its EvaluationProblem.docxroushhsiu
This document discusses the importance of common factors in psychotherapy. It outlines the contextual model of psychotherapy, which posits that there are three pathways through which psychotherapy produces benefits: 1) the real relationship between therapist and patient, 2) the creation of expectations through providing an explanatory model of the patient's difficulties, and 3) the enactment of health-promoting actions. It then reviews evidence from meta-analyses supporting several important common factors, finding large effects for the therapeutic alliance, goal consensus/collaboration, and empathy. The evidence supports the conclusion that common factors, as conceptualized in the contextual model, are important for producing the benefits of psychotherapy.
This document discusses issues related to evaluating the effectiveness of psychotherapy. It addresses questions around who should be asked to evaluate outcomes, when they should be asked, and how outcomes should be measured. It describes Hans Eysenck's early controversial claim that psychotherapy is ineffective and how subsequent meta-analyses found psychotherapy to be consistently effective. The document also distinguishes between efficacy studies conducted in controlled research settings and effectiveness studies conducted in real-world clinical practice settings. It reviews findings from efficacy studies on transdiagnostic therapies targeting underlying pathology. Finally, it discusses challenges in disseminating evidence-based therapies to practitioners and strategies like practice-oriented research to better bridge the gap between research and practice.
Our recent article about therapist effects in couple therapy. So what distinguished one therapist from another? Demographics didn’t matter but 2 other things did. First, that tried and true but neglected old friend, the alliance accounted for 50% of the differences among therapists. Those who formed better alliances across clients got better outcomes. And therapist specific experience with couples accounted for 25% of the differences. So, experienced therapists can take some solace that getting older does have its advantages—as long as it is specific to task at hand.
This document summarizes a study that explored the experiential process of Healing Touch therapy for people with moderate depression. The study used grounded theory and case study methodology. Through grounded theory analysis, the study uncovered four stages in the process of emerging from depression: 1) believing in the practitioner, self, and future self; 2) integrating all aspects of self; 3) accessing inner strength and resources; and 4) engaging with life. Case studies of individual participants supported these stages and showed trajectories of each person's experience over time. The study provides insight into how Healing Touch may help people emerge from a state of disconnection associated with depression.
This document summarizes a study that explored the experiential process of Healing Touch therapy for people with moderate depression. The study used grounded theory and case study methodology. Through grounded theory analysis, the study uncovered four stages in the process of emerging from depression: 1) believing in the practitioner, self, and future self; 2) integrating all aspects of self; 3) accessing inner strength and resources; and 4) engaging with life. Case studies of individual participants supported these stages and showed trajectories of each person's experience over time. The study provides insight into how Healing Touch may help people emerge from a state of disconnection associated with depression.
This document summarizes a study that explored the experiential process of Healing Touch therapy for people with moderate depression. The study used grounded theory and case study methodology. Through grounded theory analysis, the study uncovered four stages in the process of emerging from depression: 1) believing in the practitioner, self, and future self; 2) integrating all aspects of self; 3) accessing inner strength and resources; and 4) engaging with life. Case studies of individual participants supported these stages and showed reductions in depression scores after Healing Touch therapy. The study provides insight into how energy-based therapies like Healing Touch may help treat depression.
Advanced Regression Methods For Single-Case Designs Studying Propranolol In ...Stephen Faucher
This document discusses a study that used advanced regression methods to analyze data from a single-case design clinical trial of propranolol for treating agitation in patients with traumatic brain injury. The study was a double-blind, randomized clinical trial of 13 patients (9 men and 4 women) with traumatic brain injury. Logistic regression models found that propranolol was not associated with less agitation for most participants, though 4 participants did show a significant response. The study demonstrates how single-case design data can be analyzed using regression methods to obtain clinically and statistically significant information about psychological and medical treatments.
Homeopathy – what are the active ingredients? An exploratory study using the ...home
This study has has identified, using primary consultation and other data, a range of
factors that might account for the effectiveness of homeopathic care. Some of these, such as
empathy, are non-specific. Others, such as the remedy matching process, are specific to
homeopathy. These findings counsel against the use of placebo-controlled RCT designs in which
both arms would potentially be receiving specific active ingredients. Future research in homeopathy
should focus on pragmatic trials and seek to confirm or refute the therapeutic role of constructs
such as patient "openness", disclosure and homeopathicity
Homeopathy – what are the active ingredients? An exploratory study using the ...home
This study has has identified, using primary consultation and other data, a range of
factors that might account for the effectiveness of homeopathic care. Some of these, such as
empathy, are non-specific. Others, such as the remedy matching process, are specific to
homeopathy. These findings counsel against the use of placebo-controlled RCT designs in which
both arms would potentially be receiving specific active ingredients. Future research in homeopathy
should focus on pragmatic trials and seek to confirm or refute the therapeutic role of constructs
such as patient "openness", disclosure and homeopathicity.
Running Head MUNCHAUSEN SYNDROMEMunchausen SyndromeKr.docxglendar3
This document summarizes a research article about the role of relationships and families in healing from trauma. The article discusses how most trauma treatment focuses on the individual, but trauma is also a relational event that affects close relationships. It argues that systemic protocols addressing interpersonal difficulties in addition to intrapersonal issues are critical for healing. To illustrate, a graphic case study is presented of a family experiencing trauma due to a kidnapping, and how individual versus systemic treatment approaches would differ in addressing their needs.
Running Head MUNCHAUSEN SYNDROMEMunchausen SyndromeKr.docxtodd581
Running Head: MUNCHAUSEN SYNDROME
Munchausen Syndrome
Krystina Joseph
Columbia College
Munchausen Syndrome Article Review
Introduction
The Munchausen Syndrome Article explains about the Munchausen Syndrome, which is a rare fictitious disorder which involves the frequent hospitalization together with an intentional display of signs of sickness and pathological lying. In this regards, the management needs the security history taking with collaboration with the sound clinical processes which entails organicity exclusion in addressing the psychological problems. It is worth noting that a case which is presented having unusual symptoms of same dimensions are as well discussed. The case in this regards brings the finer nuances in the assessment of the entity (Prakash., et al 2014).
Research Question
Based on the abstract of the article, it can be denoted that the research question of the article is the need to understand more on the Munchausen Syndrome as well as the symptoms and therefore the need to ensure that such issues are solved by having a sound clinical process to handle the problem. The problem for the case as well was to find out what caused the 19-year-old housewife to vomit pink substance.
Findings
The findings depict that the 19-year-old housewife was suffering from a factitious disorder, also termed as the Munchausen syndrome. The psychometry performed also showed that there is an elevation of scales of anxiety together with hysteria. Consequently, being managed in an empathetic as well as non-confrontational manner, the psychotherapy was intended to improve the positive coping abilities while at the same time improving the interpersonal relationships which had been imparted (Prakash., et al 2014).
Research Methods Used
The methods used involved observations and clinical assessments. Observations were done by checking regularly the presence of the bloodstained vomits as well as the asthenia and any forms of skin allergy. This was carried out to ensure that the patient had no issues. The observations, as well as little conversation, showed that there were no cases of psychiatric illnesses for the patient in the past. Further, the assessment entails involves the systematic examinations which were performed within the normal limit. The psychiatric evaluation was performed together with ward observations which were intended at revealing the comfortability of the patient while in the hospital (Prakash., et al 2014).
The credibility of the Source of Information
To know the credibility of sources, the authors are scrutinized where their qualifications and their areas of experience assessed to understand whether the information provided is related to the topic at hand. For this article, it can be denoted that all the information provided is credible. This is because all the four authors who contributed to the article have sufficient skills and knowledge pertaining to health-related disorders, and thus, their pieces of information.
Anger Treatment For Adults A Meta-Analytic ReviewScott Faria
This document summarizes a meta-analysis of 50 studies on anger treatment interventions for adults. The analysis found that adults who received treatment showed significant and moderate improvement in anger compared to untreated adults, and large improvement from pre-treatment scores. Treatment reduced negative affect, aggressive behaviors, and increased positive behaviors. Gains were also maintained at follow-up. The meta-analysis contributed to the literature by focusing only on adult studies, including more published and unpublished research, and allowing analysis of moderator variables and different dependent measures.
Towards an evidence informed adventure therapy implementing feedback informed...Will Dobud
ABSTRACT
As an intervention for adolescents, adventure therapy has evolved considerably over the last three decades with support from multiple meta- analyses and research input from both residential and outpatient services. Tainted by a history of unethical practice and issues of accountability, this article explores the question of how adventure therapy can meet a standard of evidence preferred by policymakers and funding bodies on the international stage. In this case, feedback-informed treatment (FIT) is presented as a means for routine outcome management, creating a framework for adventure therapy which aims to improve the quality of participant engagement while maintaining and operationalizing today’s definitions for evidence-based practice. A case vignette illustrates the use of FIT with an adolescent participant engaged on a 14-day adventure therapy program.
Benchmarking the Effectiveness of Psychotherapy Treatment for .docxikirkton
Benchmarking the Effectiveness of Psychotherapy Treatment for Adult
Depression in a Managed Care Environment: A Preliminary Study
Takuya Minami
University of Utah
Bruce E. Wampold and Ronald C. Serlin
University of Wisconsin–Madison
Eric G. Hamilton
PacifiCare Behavioral Health
George S. (Jeb) Brown
Center for Clinical Informatics
John C. Kircher
University of Utah
This preliminary study evaluated the effectiveness of psychotherapy treatment for adult clinical depres-
sion provided in a natural setting by benchmarking the clinical outcomes in a managed care environment
against effect size estimates observed in published clinical trials. Overall results suggest that effect size
estimates of effectiveness in a managed care context were comparable to effect size estimates of efficacy
observed in clinical trials. Relative to the 1-tailed 95th-percentile critical effect size estimates, effec-
tiveness of treatment provided in this setting was observed to be between 80% (patients with comorbidity
and without antidepressants) and 112% (patients without comorbidity concurrently on antidepressants) as
compared to the benchmarks. Because the nature of the treatments delivered in the managed care
environment were unknown, it was not possible to make conclusions about treatments. However, while
replications are warranted, concerns that psychotherapy delivered in a naturalistic setting is inferior to
treatments delivered in clinical trials appear unjustified.
Keywords: benchmarking, effectiveness, managed care, clinical trials, depression
More than a decade has passed since estimating the effect of
psychotherapy as it is delivered in natural settings was identified as
a critical issue in psychotherapy research (e.g., Barlow, 1981;
Cohen, 1965; Luborsky, 1972; Seligman, 1995; Strupp, 1989;
Weisz, Donenberg, Han, & Weiss, 1995). Although the benefits of
psychotherapy have been investigated in laboratory environments
with randomized clinical trials (RCTs) and found to be substantial
as early as the late 1970s (Smith & Glass, 1977; also Smith, Glass,
& Miller, 1980), surprisingly little is known about the effects of
psychotherapy in natural settings. The dichotomy of laboratory and
natural settings was emphasized by Seligman (1995), who discrim-
inated between efficacy, which is now used to denote the effects of
psychotherapy in RCTs, and effectiveness, which is used to denote
the effects of psychotherapy in clinical practice.
The few studies that have investigated effectiveness over the
years have provided mixed results, attributed in part to a variety of
methodologies used to investigate effectiveness because of diffi-
culty in using a randomized control group design in natural set-
tings. Notably, three methods have been used to estimate the
effects of psychotherapy in natural settings: clinical representa-
tiveness, direct comparison, and benchmarking. Clinical represen-
tativeness studies, including some of the analyses conducted by
Smith et al ...
Similar to Of Dodo birds and common factors: A scoping review of direct comparison trials in adventure therapy (20)
To Chart a Course: How to Improve Our Adventure Therapy Practice Will Dobud
Presented at the 8th International International Adventure Therapy Conference in Sydney 2018.
In the most comprehensive adventure therapy study published to date, Bowen and Neill (2013) argued that “a small percentage of adventure therapy programs undergo empirical program evaluation” (p. 41), that being less than 1%. With about three decades of research supporting the efficacy of adventure therapy, though we still have questions about dose-effect and for who adventure therapy is most effective (Gass, Gillis, & Russell, 2012; Gillis & Speelman, 2008; Norton et al., 2014) and adventure therapy performing on par with other therapeutic modalities (Dobud & Harper, 2018), there is little question that adventure therapy stands as a bonafide option as a therapeutic treatment. That is the good news.
With the publication of the first meta-analysis of psychotherapy outcomes, Smith and Glass (1977) found that participants engaging in some type of therapy were bever off than 70-80% of those that received no therapy at all. These encouraging effect sizes were on par with or outperformed many common medical treatments, such as taking an ibuprofen for a headache (Miller, Hubble, Chow, & Seidel, 2013). The psychotherapy clinical trials were conducted with research participants randomly receiving either some type of therapeutic interventions or no treatment at all (Smith & Glass, 1977). The researchers further acknowledged that when participants were randomly selected to receive one of
two different therapies, such as Cogni`ve-Behavioural or Psychodynamic Therapy, no difference in outcomes could be
found despite the theoretical differences of the two. Despite the limited publications and dissertations where adventure therapy was compared to a therapeutic intervention containing no adventurous components, we have a similar issue that adventure therapy tends to perform on par, no greater and no worse, than its counterparts (Dobud & Harper, 2018; Harper, 2010). The specific differences that suggest certain therapies are unique hold little to no variance in outcomes (Ahn & Wampold, 2001). Since Smith and Glass' (1977) pinnacle study, outcomes across psychotherapy have flatlined. Despite a ballooning of new diagnostic criteria and mushrooming of empirically supported treatments, there has been no improvement in outcomes (Asay & Lambert, 1999; Miller et al., 2013; Wampold, 2001). This presentation will attempt to untangle some of the factors put forward by researchers over the last two decades to illustrate those factors most likely to lead to improved therapeutic outcomes, such as establishing goal consensus with clients, improving the therapeutic relationship, and monitoring outcomes (Lambert, 2010; Wampold, 2001). Though this workshop will present some of these important findings, the presentation will stage my experiential journey in reaching out to coaches, researchers, and supervisors in trying to improve my outcomes as a therapist, one client at a time.
Adventure Therapy Professional Development - 3 March 2017Will Dobud
Here are the slides from an adventure therapy professional development workshop I ran in Adelaide in March of 2017. The seminar discussed the importance of engagement, a therapeutic relationship, and provided a brief introduction to Feedback-Informed Treatment (FIT) and how we have incorporated FIT into our adventure therapy program.
Client-Directed, Recovery-Oriented Practice: Feedback-Informed Treatment to I...Will Dobud
This 90-minute workshop was delivered at the at the 5th Rural and Remote Mental Health Symposium in Kingscliff, New South Wales on the 2nd of November 2016.
Co-Adventuring in Adventure Therapy: Presented at the OEASA State Outdoor Edu...Will Dobud
This hour workshop was presented on the 18th of November 2016 at the Outdoor Educators Assiciation of South Australia's State Outdoor Educators Conference in Adelaide, South Australia.
Presented at the Australian Association for Bush Adventure Therapy's 2016 National Forum in Adelaide. Topics include Feedback-Informed Treatment, Adventure Therapy, Research, and what works in therapy with children, adolescents, and families.
Exploring Adventure Therapy as an Early Intervention for Struggling AdolescentsWill Dobud
This paper presents an account of a research project that explored the experiences of adolescents struggling with behavioural and emotional issues, who participated in a 14-day adventure therapy program in Australia referred to by the pseudonym, ”Onward Adventures.” All participants of this program over the age of 16 who completed within the last two years were asked to complete a survey. Additionally, the parents of these participants were invited to complete a similar survey. The qualitative surveys were designed to question participants’ and parents’ perceptions of the program (pre- and post-), the relationships (therapeutic alliance) built with program therapists, follow-up support, and outcomes of the program. Both participants and parents reported strong relationships with program leaders, stressed the importance of effective follow-up services, and perceived positive outcomes when it came to self-esteem and social skills, seeing comparable improvement in self-concept, overall behaviour, and coping skills.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Lecture 6 -- Memory 2015.pptlearning occurs when a stimulus (unconditioned st...AyushGadhvi1
learning occurs when a stimulus (unconditioned stimulus) eliciting a response (unconditioned response) • is paired with another stimulus (conditioned stimulus)
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
10 Benefits an EPCR Software should Bring to EMS Organizations Traumasoft LLC
The benefits of an ePCR solution should extend to the whole EMS organization, not just certain groups of people or certain departments. It should provide more than just a form for entering and a database for storing information. It should also include a workflow of how information is communicated, used and stored across the entire organization.
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
2. therapeutic recreation, eco-therapy and adventure-based coun-
seling, to name a few. AT utilizes experiential learning methods,
physical movement, challenge and risk-based activity, the gener-
ating and use of metaphor, and involvement with natural envi-
ronments [22,23]. Described as either an adjunct to an existing
therapy or a stand-alone treatment, AT literature has substantially
increased over the last two decades [20,24] yet struggles to move to
an evidence-based modality due to its diverse manifestations and
lack of theoretical development as a therapy [25].
1.1. Purpose of this scoping review
Harper cautioned against ignoring the Dodo's ruling of the
common factors in AT, declaring that “evidence of change may be
demonstrable in outcome studies… yet explaining how that change
occurred is highly implausible” [26, p. 43]. For Baldwin, Persing,
and Magnuson, it seems contradictory “to suggest that adventure
education programs foster growth in the participants (i.e., out-
comes) while at the same time asserting there is little under-
standing of how this change occurs” [27, p. 168]. As practitioners
and researchers embedded in the AT community, this review was
driven by our interest in locating the specific ingredients, if any,
contributing to AT outcomes. This scoping study follows guidelines
as described by Arksey and O'Malley [28] to review studies directly
comparing AT delivered in clinical settings with other therapeutic
services in support of the drive toward evidence-based practice.
1.2. What are the common factors?
Frank and Frank proposed “that the features common to all
types of psychotherapy contribute as much, if not more, to the
effectiveness of those therapies than do the characteristics that
differentiate them” [11, p. 20]. With resounding evidence sup-
porting the effectiveness of therapy across models [4,7,12,14], direct
comparison trials have historically found little variance in treat-
ment differences [see 29]. Asay and Lambert [4] reviewed decades
of outcome research and estimated the variance attributed to the
common factors, ranking extratherapeutic factors at 40%, rela-
tionship factors at 30%, hope and placebo at 15%, and the model or
technique at 15% as well. While Asay and Lambert depicted these
factors in a well-arranged pie chart, Wampold [30] argued for a
more fluid understanding of the common factors, best understood
by separating treatment effects from the extratherapeutic factors.
Instead, 86% of the variance was due to these extratherapeutic
factors, described by Thomas as the “components in the life and
environment of the client that affect the occurrence of change, such
as the client's inner strengths, support system, environments, and
chance events” [8, p. 203]. Wampold [30] attributed the remaining
14% to the treatment that included the alliance, model differences,
hope and expectancy. Laska, Gurman, and Wampold [31] further
listed the effects of different therapeutic variables from 715 studies,
with more than 32,700 patients listing significantly larger effects
for the therapeutic relationship and agreement on goals than spe-
cific treatment differences or model adherence.
In randomized clinical trials, researchers have commonly paired
established therapies, with no treatment or nonspecific control
groups. No treatment controls lack the common factors, including a
therapeutic relationship and a rationale for therapeutic healing that
elicits hope and expectancy [9]. Attempting to control for these
factors and placebo effects, nonspecific control groups have placed
research participants into nontherapeutic controls. An example of
this in AT is evident in the often-cited 1968 study of Outward
Bound's 21-day program on recidivism rates for adjudicated youth
by Kelly and Baer which used a “traditional training school expe-
rience” [32, p. 89] as the comparison. Because a training school
lacks the therapeutic intent and common factors associated to
therapy, the findings were not included in this review. Interestingly,
however, the three Outward Bound schools used in this study with
similar sample sizes produced varied results which we find inter-
esting relative to our study aims. While the Colorado School re-
ported a recidivism rate at 0% and Hurricane Island at 11%, the
Minnesota School reported a recidivism rate of 42%, worse than the
training school it was compared with (37%), leaving readers to
wonder, what factors differentiated these programs all operating
under the same organization? It is because of this lack of theoretical
understanding that AT continues to espouse positive treatment
outcomes without being able to articulate why [26].
Common factors research brings into question the current state
of evidence surrounding AT, how it works, and how outcomes can
be improved. Random assignment to treatment groups has been a
challenge for AT, as it raises ethical concerns about placing people
in experimental conditions outside their treatment preference [33].
Still, calls are made for more scientific verifiability and fidelity in AT
practice [24,34]. For these authors, the question persists if the
Dodo's verdict applies to a therapy that is often viewed as alter-
native due to the many factors that have been assumed to
contribute to change [20,35].
2. Methods
2.1. Scoping review methodology
We preferred to conduct this review as a scoping study “to map
rapidly the key concepts underpinning a research area and the main
sources and types of evidence available” [28, p. 21, emphasis in
original] across the AT literature. Though without a universal
definition or method, this methodology has been used to review
previously under-explored bodies of knowledge [i.e. 36]. With the
diversity in AT practice [22] this method provided an opportunity
“To clarify a complex concept and refine subsequent research in-
quiries” [37, p. 1]. For Gough, Thomas, and Oliver [38], it is impor-
tant to situate the boundaries between systematic and scoping
reviews. Where systematic reviews seek evidence to inform de-
cisions, a scoping review intends to provide a new way of under-
standing. Our search for literature is outlined below using Arksey
and O'Malley's [28] five-stage framework. A thorough description
of the research methodology is shared for replicability [39].
2.1.1. Stage 1: identifying the research question
This review asked the research question: Are there specific
components to AT contributing to outcomes? With the purpose of
exploring the findings from direct AT comparison studies featuring
an experimental treatment group. The literature includes the broad
understanding of AT defined by Harper et al. [22] and aimed to map
specific therapeutic factors identified as AT.
2.1.2. Stage 2: identifying relevant studies
To increase depth, Arksey and O'Malley [28] recommended
searching for studies from a variety of sources including electronic
databases, references lists, hand searching relevant journals, and
existing networks or conferences. Primo Search was used to scan
the major databases, including EBSCOhost, Ovid, SAGE Journals
Online, PsychINFO, Google Scholar, ProQuest, ERIC, and Cambridge
Journals Online. The advanced search option was utilized on July 31,
2017 with the search terms “adventure therapy” or “wilderness
therapy” as part of the title or keywords from peer-reviewed
journal articles only. These keywords were chosen for their domi-
nance in the English literature [20,35]. This search located 752
peer-reviewed articles, presented in Fig. 1. A PRISMA flow diagram
[40] provides a visual representation of our search process. A
W.W. Dobud, N.J. Harper / Complementary Therapies in Clinical Practice 31 (2018) 16e24 17
3. secondary search was conducted through ProQuest Dissertation
Publishing to locate possible unpublished AT dissertations. Using
the same search terms, 128 dissertations were located. Last, a hand
search through reference lists from AT reviews, seminal studies
[e.g., 41], and field-related journals not appearing in our database
search was conducted. The journals hand searched were the Journal
of Experiential Education, Child and Youth Care Forum, Australian
Journal of Outdoor Education, and Residential Treatment for Children
and Youth. One additional publication was located, resulting in a
final count of 881.
2.1.3. Stage 3: study selection
These articles and dissertations (n ¼ 881) were first screened by
review of title and abstract. Exclusion of publications included the
removal of duplicates (n ¼ 47), theoretical papers (n ¼ 30), quali-
tative studies (n ¼ 251), meta-analyses (n ¼ 8), mixed-methods
studies without controls (n ¼ 16), reviews of literature (n ¼ 29),
articles not pertaining to AT (e.g., outdoor education and adventure
tourism) (n ¼ 199), published in a language other than English
(n ¼ 4), and editorials or reports (n ¼ 192). The remaining quanti-
tative studies (n ¼ 105) were then full-text reviewed. At this stage,
exclusion of studies included those without control groups (n ¼ 68)
and those with no treatment controls or experimental conditions
lacking the common factors, such as a therapeutic relationship
(n ¼ 23). In distinguishing the difference between experience-
based adventure program and those determined to be therapy,
Gillis, Gass, and Russell stated that “Researchers must also present
what is occurring in the treatment program that is labeled “ther-
apy” and how (or if) wilderness adventure therapy is being deliv-
ered” [42, p. 230]. Only studies indicating the presence of qualified
practitioners working in clinical settings were included. If a control
group was labelled therapeutic [e.g. 42] but the presence of a
therapeutic rational or practitioner was missing, the study was
excluded. This two-stage exclusion process resulted in 13 publica-
tions meeting our criteria for review.
2.1.4. Stage 4: charting the data
Stage 4 is more akin to a narrative than systematic review in that
we explored the 13 direct comparison trials using a
descriptiveeanalytical method [39], which involved charting pro-
cess information, such as the therapeutic rationale for AT or au-
thors' claims about specific ingredients. While Arksey and O'Malley
[28] do not recommend searching for literature based on research
method alone, we felt that direct comparison trials could help
explore our research question in that they offered an opportunity to
locate studies examining these distinctions [43]. That said, we did
not assess the quality of these studies [37,44]. The articles are
charted chronologically in Table 1, by author, year of publication,
sample size, a brief description of the experimental conditions, and
research measure(s) used. We also located text from each study
that provided a conclusion or clarifying comment on the study's
outcome.
2.1.5. Stage 5: collating, summarizing, and reporting the results
We reviewed the studies individually rather than collating the
results [37,39]. We examined each study for a therapeutic rationale
clarifying why one experimental condition should provide signifi-
cant outcomes and a reasoning for why that condition would prove
effective. Where available, this rationale is presented.
3. Results
Our search for direct comparison trials located studies that
included outpatient AT services [e.g. 45], wilderness therapy (WT)
programs [e.g., 45], different components of WT programs [e.g., 47],
as an adjunct to treatment residential programs [e.g. 48], and an
Primo Search
-
(n = 752)
ProQuest Dissertations Search
(n = 128 dissertations)
Records after duplicates removed
(n =47)
Records screened by
(n = 834)
Records excluded
Theoretical Papers: 30
Qualitative Studies: 251
Meta-Analysis: 8
Mixed Methods: 16
Reviews: 29
Not AT: 199
Other Language: 4
Editorials/Reports: 192
(n = 728)
Full-text quantitative articles
screened for eligibility
(n = 105)
Full-text articles excluded
No comparison group: 69
No treatment control group: 23
(n = 91)
Direct comparison
studies included
(n = 14)
Hand Search
(n = 1)
(n=881)
Fig. 1. Flow diagram of search terms, inclusion criteria and findings.
W.W. Dobud, N.J. Harper / Complementary Therapies in Clinical Practice 31 (2018) 16e2418
4. integrated WT in an inpatient program [e.g. 49]. Outcomes were
measured by recidivism rates [e.g. 50], length of treatment in
relation to outcomes [e.g. 51], and using behavioral or emotional
measures [e.g., 52].
3.1. Presentation of included studies
Comparing the effects of the Sierra II program, an adapted
version of Outward Bound, to established probation services, Call-
ahan [53] found the program to deliver the intended outcomes for
Locus of Control and Self-Esteem. The author talks in length about
the therapeutic model being delivered, stating that Sierra II is “an
intense physical and guidance program designed to optimize the
change process” [53, p. 70]. The program teaches problem-solving
skills and responsibility to improve self-efficacy through
mastering certain skills, and participants should become motivated
to change and able to overcome adverse situations through having
experiences of success and mastery [54]. This study, however,
found no statistically significant difference in outcomes between
Sierra II and traditional probation services, which were not
described in any length but involved counseling and rehabilitation.
The author argued for more research attempting to locate the
Table 1
Direct Comparision Studies in AT.
Author (Year) N Therapies Research Measures Author Comments on Efficacy
Callahan (1989) [53] 70 e Adapted Outward Bound
e Traditional probation
treatment
Tennessee Self-Concept Scale
Modified Internal-External Scale
Generalized Expectancy of Success
Scale
“Further study should be undertaken to discriminate between Sierra II
components effecting behavior and achievement and those related to
individual participant maturation” [p. 8].
Bandoroff (1992)
[47]
66 e Wilderness survival
program with family
therapy experience
e Wilderness survival
program without family
therapy experience
The Family Wheel Evaluation
The Family Assessment Measure III
The Self-Reported Delinquency
Checklist
The Revised Behavior Problem
Checklist
The Self Description Questionnaire
III
“Adolescent ratings of delinquency dropped for both Family Wheel
adolescents and nonparticipating adolescents. Parent ratings of problem
behavior also improved for both groups. Moreover parent and adolescent
reports of police and court contacts decreased for both Family Wheel
participants (3) and nonparticipants (21). Adolescent ratings of self
concept also revealed increases in self concept for adolescents in the
Family Wheel and adolescents who took part in the standard wilderness
program only” [p. 186].
Hyer et al. (1996)
[48]
219 e Five-day Outward Bound
e Treatment as usual
Mississippi Scale for Combat
Related PTSD
Impact of Events Scale
“Overall results suggest that [the Outward Bound experience] as an
adjunct to [Specialized Inpatient PTSD Units] produces no distinct
discernible effect on general or PTSD-specific symptoms” [p. 272].
Romi & Kohan (2004)
[52]
94 e Wilderness group
e Alternative group
e Contrast group “without
any specific intervention”
Self-Esteem Questionnaire
Locus of Control Questionnaire
“The [wilderness program] group stood apart in its results, showing
increased self-esteem in four out of six factors compared to the contrast
group, but there was no significant change compared to the Alternative
Program group” [p. 115].
Guthrie (2004)
[56]
72 e Therapeutic services with
AT
e Therapeutic service
without AT
Ohio Youth Problems, Functioning,
and Satisfaction Scales
“No significant difference in post-test scores between the two groups was
found, suggesting that neither Adventure Therapy nor ‘treatment as
usual’ was more effective than the other.” [p. iii]
Jones, Lowe, & Risler
(2004)
[57]
35 e WT program
e Residential program
Detention Assessment Instrument “This result is important in indicating that, at least in this case, wilderness
programs were not any more or less effective than another residential
program offered to juveniles.” [p. 64]
Eikenaes et al. (2006)
[49]
53 e Integrated WT
e Inpatient program
Statistical Clinical Interview for
DSM-IV
Symptom Check List 90
The Beck Depression Inventory
The Phobic Avoidance Rating Scale
The Personality Diagnostic
Questionnaire 4þ
Self-Efficacy Inventory
“Results were not significantly different in the two treatment conditions”
[p. 279].
Larson (2007)
[58]
61 e Adventure camp
e Behavior modification
Piers-Harris Children's Self-
Concept Scale
“The lack of a significant statistical difference between the two groups of
this study would seem to be supported by previous research” [p. 325].
Walsh & Russell (2010)
[50]
43 e 21-day WT program
e Correctional services
Recidivism reported by probation
officers
“No significant differences in recidivism rates, school participation, or
employment rates were found” [p. 221].
Magle-Haberek et al.
(2012)
[46]
118 e Outdoor behavioral
healthcare
e Residential treatment
centers
Outcome Questionnaire Family of
Instruments
“This research demonstrated that length of treatment does not predict
change in [Outcome Questionnaire] measures” [p. 216].
“This finding may also imply that change is likely determined by clients'
individual treatment needs, rather than that of the program” [p. 212].
Tucker et al. (2013)
[45]
1135 e AT
e AT þ psychological
counseling
e Psychological counseling
e Psychological and group
counseling
Ohio Youth Problem Severity Scale “All clients who participated in any type of counseling presented on
average with high levels of problem severity… while clients who were
given no counseling services, but a variety of support services, did not
make any significant improvements… In addition, clients who
participated in AT presented at intake with significantly higher levels of
problem severity compared to clients who participated in other types of
counseling… This is not surprising since clinicians often referred
challenging clients to AT in addition to counseling” [p. 172].
Paquette & Vitaro
(2014)
[51]
220 e 8e10-day WT program
e 17e20-day WT program
A scale was created to measure
negative peer influence and
substance abuse issues
“The absence of a significant relationship between the duration of the
program and the improvements that have been observed in the
participants brings us to believe that the intervention has not played a
direct causal part” [p. 247].
Rosenberg, Lange,
Zebrack, Moulton, &
Kosslyn (2014)
[59]
199 e First outdoor adventure
program
e Second outdoor
adventure program
Body Image Scale
Self-Compassion Scale-Short Form
Psychological Screening Inventory-
2
“We also compared how the two groups… fared from pretest to posttest,
and found no differences on any of the variables of interest. That is, P2
participants did not have a significant additional benefit (nor did they fare
worse) compared to P1 participants” [p. 634].
W.W. Dobud, N.J. Harper / Complementary Therapies in Clinical Practice 31 (2018) 16e24 19
5. specific healing components of the Sierra II program as this study
could not find one specific ingredient, for example, rock climbing,
to be more beneficial than traditional probation services.
Bandoroff and Scherer [55] compared the outcomes of those
who had completed a 21-day WT program with those who had
completed the same program with a supplementary family therapy
workshop. The additional workshop reunited adolescents with
their parents for an intensive program of additional trekking, family
therapy sessions, and metaphoric experiences to help transition the
adolescents home and improve communication. The authors re-
ported positive effects for both conditions, yet there was no dif-
ference in outcomes in self-concept and parent reports of problem
behavior for families that took part in the additional four-day
family therapy workshop. In this case, supplementary interven-
tion did not predict further improvements at the six-week follow-
up.
Hyer et al. [48] explored the effects of incorporating a five-day
Outward Bound program in two Department of Veterans Affairs
Specialized Inpatient PTSD Units (SIPUs). Comparison groups were
created of Vietnam veterans who took part in either the Outward
Bound (n ¼ 108) or treatment as usual (n ¼ 111), which included
group and individual therapy in a therapeutic residential setting.
The study suggested that using Outward Bound experiences “as an
adjunct to SIPU treatment produces no distinct discernible effect on
general or PTSD-specific symptoms” [48, p. 272]. Interestingly, the
two settings in which this study took place outperformed each
other.
Romi and Kohan [52] established a six-day wilderness program
for disengaged youth in Israel to compare outcomes to an alter-
native residential program including a variety of activities. Facili-
tated by a trained therapist, the wilderness program should help
adolescents to take control of their immediate experiences, which
would lead to improved self-esteem and locus of control, two do-
mains measured by the researchers. This study also included a
control group “without any specific intervention program” [52, p.
123]. The wilderness program and alternative camp both out-
performed the nonspecific control group, yet no significant differ-
ence was found between the wilderness and alternative camp.
Guthrie [56] explored whether incorporating a manualized
version of group AT would improve problem severity as reported by
parents or agency workers compared with treatment-as-usual
services for children diagnosed with mental disorders. The author
hypothesized that AT would help participants to change their
thoughts, feelings, and behaviors through problem-solving and
cooperative activities. The study found both AT and treatment-as-
usual to be equally effective.
Jones et al. [57] compared the effects of splitting a sample of 35
young male participants, who were placed in either a WT or resi-
dential group home program. The authors found that “wilderness
programs were not any more or less effective than another resi-
dential program offered to juveniles” [57, p. 64]. The study did not
discuss the components of either experimental group, making it
difficult to identify factors contributing to the outcomes, but one
can reason that while time spent in nature and the camping
experience was beneficial, it was no more so than being inside at a
group home. Both experimental groups, however, operated in
group settings, which could be one factor contributing to the
equivocal effects.
Eikenaes et al. [49] integrated WT to compare outcomes using a
myriad of questionnaires with those engaged in the hospital's
standard inpatient program in an attempt to improve outcomes in
an inpatient program for patients diagnosed with avoidant per-
sonality disorder. These hospital services were interpersonally
focused using groups with a psychodynamic framework. The re-
searchers argued that integrating WT would “intensify the
interpersonal focus through interpersonal tasks” [49, p. 276], which
would lead to feelings of success and mastery. The “overall results
were not significantly different in the two treatment conditions”
[49, p. 279]. No differences in outcomes in depression, phobic
avoidance, or self-efficacy continued at a follow-up measure con-
ducted one year post discharge.
Larson [58] studied the self-concept of 31 adolescents who
voluntarily engaged in an adventure camp compared to adolescents
receiving behavior modification through a social services agency. A
five-day adventure camp provided an experience where adoles-
cents shared equal responsibility in completing daily tasks required
for camping in a wilderness setting. These tasks, the author
explained, are meant to help adolescents to improve their self-
concept, social skills, and appreciation for natural environments.
The study “would appear to support the notion that adventure
camp programs do not produce a significant difference between the
two groups studied” [58, p. 327]. Based on the author's literature
review, this study “supports the findings from previous studies…
that adventure camps illicit no change in a participant's self-
concept when compared to other groups who do not participate
in adventure camp programs” [58, p. 326].
Walsh and Russell [50] compared a 21-day WT program to a
“control group of similar youth referred to some other correctional
disposition” [50, p. 399]. The authors proposed that change on WT
programs occur, as:
“wilderness and adventure experiences for adolescents enhance
self-competency through wilderness and adventure-based
travel in remote environments in an intense social milieu,
which leads to the development of intra- and interpersonal
skills strongly linked to the concept of resiliency, which leads to
an enhanced sense of hope for adolescents that they can over-
come certain challenges in their lives, which ultimately results
in a reduction of recidivism after the completion of the wil-
derness experience.” [50, pp. 398e399]
Unfortunately, details of the ‘correctional’ services were not
discussed, making it difficult to explore the components eliciting
change. Recidivism rates between the two groups studied, which
were reported to the researchers by probation officers, were
approximately 42% for the control group and 44% for WT. No sta-
tistically significant differences were found.
Magle-Haberek et al. [46] explored the difference in outcomes
and program components between outdoor behavioral healthcare
(OBH) programs and residential treatment centers. OBH programs
are designed to work by immersing adolescent participants into a
wilderness environment, using physical activity and social inter-
action in group settings. Clinicians in some of the residential
treatment centers also reported using some form of AT technique,
which were considered, though the researchers could not find any
significance to indicate that implementing AT was predictive of
change in residential settings. In this study, the 68 participants of
residential programs had on average longer lengths of treatment
than the 50 OBH participants, though length of treatment was not
predictive of change. Residential programs did, however, outper-
form the OBH programs, though this may be due to unequivocal
samples of research participants. Clients admitted into the resi-
dential programs reported more distress on outcome measures,
which is discussed further in the discussion section.
Paquette and Vitaro [51] randomly assigned young offenders to
two WT programs, one lasting 8e10 days (n ¼ 101) and another
17e20 days (n ¼ 119). The authors illustrated several elements
crucial to the WT process, naming “experiential education, the use
of outdoor activities to incorporate a certain level of risk and re-
sponsibility, the context of the wilderness and the less traditional
W.W. Dobud, N.J. Harper / Complementary Therapies in Clinical Practice 31 (2018) 16e2420
6. role of the counsellor” [51, p. 233]. Additionally, “the longer… the
duration of the program, the better the results should be if the
results depend on the program, especially if the duration is
experimentally manipulated through random assignment of the
participants” [51, p. 234]. Using a customized scale to measure
negative peer influence and substance abuse, the authors noted
that “no matter the length of the expedition phase, the observed
decrease in antisociality levels of participants at three months was
maintained without great variation at six months” [51, p. 239]. The
authors pointed out that the “absence of a significant relationship
between the duration of the program and the improvements that
have been observed in the participants brings us to believe that the
intervention has not played a direct causal part” [51, p. 247].
Rosenberg et al. [59] inquired whether young adult cancer
survivors, having already completed a six-day adventure program,
would benefit from a second adventure program. The authors hy-
pothesized that participants would be sensitized to the program
and benefit more from a second adventure-based experience.
Findings suggest that engagement on the first program led to
improved self-esteem, body image, self-compassion, and reduced
depression. The authors found that though participating in a sec-
ond program helped in similar ways, participants “were no better
off psychologically than participants who take part for the first
time” [59, p. 622].
One study found a significant improvement in problem severity
and functioning by adding AT services to community-based coun-
seling services [45]. The study reported larger decreases in problem
severity among participants engaged in counseling services with an
AT component. Though both counseling with or without compo-
nents of AT produced significant results, these authors advised
caution when interpreting the findings due to unbalanced treat-
ment groups, and participants referred to AT services reported
greater levels of distress than those in the counseling-only group.
4. Discussion
With many types of reviews available, we preferred a scoping
review to map the available evidence on the specific therapeutic
factors of AT as opposed to a more systematic approach of
compiling all the available literature [38]. Identifying what can be
known about AT specifically is just one step toward understanding
the potential of this approach. Of the 13 direct comparison studies
in this review, it was clear that no analogous version of AT exists.
The diversity of practice in the international context shows that AT
could be effectively delivered over varying lengths of time, in
different settings, and for different populations. No matter the
rationale for why some certain version would work better than the
next, AT showed it could be as effective as its counterpart in the
included studies. In 10 of the 13 studies, intense social environments
were assumed to contribute to positive outcomes. Three mentioned
that problem-solving activities would lead to feelings of success or
mastery, terms referred to in six of the studies, which may illustrate
the influence of Walsh and Golins' Outward Bound process model
[54]. Physical involvement was mentioned in five studies as playing
a role in relation to outcomes. Seven studies reported that time in
nature and pristine wilderness environments would provide a more
effective setting for therapeutic healing to occur and asserted that
time in nature was an active ingredient contributing to outcomes.
When compared to conditions lacking in these factors, however,
the specifics of each appeared to hold little influence.
In the two studies [45,46] where differences were found, intake
scores showed higher levels of distress for those in the better
performing intervention. Higher levels of distress at intake tends to
be one of the best predictors of change rather than diagnosis, de-
mographics, or the specifics of the treatment [16]. This may
emphasize that the context in which AT is provided regarding the
qualities of the therapists, the extratherapeutic factors of the cli-
ent's life, and the quality of engagement and relationship may
specifically play a larger role in how change occurs.
Though therapy is situated in a domain that privileges evidence
gleaned from randomized clinical trials [33], the active ingredients
regarded as unique to AT made little difference in outcomes across
the 13 studies. With calls for experimental research to produce
evidence of efficacy [63], researchers may benefit from investi-
gating our current understanding of how AT actually works rather
than comparing AT to other bona fide therapies. Does more pre-/
post-outcome research improve our understanding of how AT
works, or does it continue to emphasize that those engaged in some
sort of therapeutic healing are better off than those receiving no
treatment at all? If the latter, it may be revealing for researchers to
conduct dismantling studies to determine the essential factors
contributing to program outcomes [23,61,64]. Similar to child and
youth therapeutic residential programs, many WT and OBH pro-
grams have a curriculum of treatment phases to move through,
minimum or fixed lengths of stay, and specific skills that must be
attained while incorporating components of family, individual, and
group therapy [35]. These conditions, as well as the specific factors
identified in this review (See Table 2), could be further dismantled
by removing one of them from each experimental condition in
search of their significance. A limitation to this review, discussed
further below, is the lack of definition and inconsistency regarding
what treatment was actually provided to the AT participants.
Instead of continuing to conduct outcome research under the
umbrella of AT or calling for more comparison groups, it may be
important to ask what can be done to improve outcomes. Because
anecdotal justifications of AT hold little evidence in relation to
outcome, a dismantling study could help illustrate what thera-
peutic forces are actually at work. If the Dodo's verdict holds true,
the importance of one ingredient over another would continue to
prove small, inviting the question of what factor is truly essential
for AT's effectiveness.
These findings support a vision of AT that includes a variety of
approaches, settings, and contexts and is in alignment with an in-
ternational expression of AT [22]. With this review and ongoing
consideration about how to define AT or how it works [24,65,66], a
more compelling view of AT would acknowledge that the unique
components of AT may not have greater influence than the factors
shared with all other forms of therapeutic interventions. With this,
AT does face a similar challenge to the many models of therapy
[7,11]. Stated in the conclusion of psychotherapy's first meta-
analysis published in 1977, Smith and Glass noted that “uncondi-
tional judgments of superiority of one type or another of psycho-
therapy, and all that these claims imply about treatment and
training policy, are unjustified” [14, p. 780]. Moreover, these as-
sumptions place researchers and practitioners “in the rather
embarrassing position of knowing less than have been proven” [14,
p. 780]. For example, not once in this review did an intervention
utilizing a wilderness environment outperform an indoor setting. If
not for the specifics, the common factors may hold clues as to what
is affecting change.
We simply cannot rely on circumstantial understandings of AT to
do the work for us, nor rest on the growing evidence from outcomes
studies. With a history riddled by unethical practice, unqualified
staff, unprincipled techniques, and even client deaths on WT pro-
grams [67e69], this review does not suggest an ‘anything goes’
philosophy. On the contrary, the common factors theory does not
apply to treatments proven to hurt people [5]. Instead, it illustrates
that when a client and therapist engage in an emotionally charged
therapeutic relationship with an agreed-upon narrative for which
therapeutic healing will occur, positive outcomes emerge [7,11].
W.W. Dobud, N.J. Harper / Complementary Therapies in Clinical Practice 31 (2018) 16e24 21
7. Inappropriately, acceptance into the domain of evidence-based
practice involves providing proof of active ingredients contributing
to outcomes and finding what precise technique or disorder fits best
within the AT framework [26]. With the Dodo's verdict that all are
deserving of prizes, the therapeutic forces of AT may be the same
factors contributing to change across various modalities.
4.1. Limitations
For reviewing direct comparison trials, Wampold [43] recom-
mended using only studies that contain manualized treatments in
order to track the specifics of each treatment. For this review, each
study would have needed an in-depth rationale for each experi-
mental condition. The lack of an agreeable definition does create a
limitation in understanding what it is that these studies are pur-
porting to call AT. Where manualized therapies, like cognitive
behavioral therapy, include a set of specific techniques or in-
gredients that can be more easily isolated, the lack of coherent
presentations of AT may have distorted these findings. With a small
sample of available studies, we preferred to conduct a scoping
study as AT practice remains varied and is not a manualized mo-
dality [25]. Limited discussion about the experimental groups and
the treatments provided were available, leaving it difficult in some
cases to determine whether a control group was, in fact, designed
to be therapeutic. Given that half of the studies included were
conducted over a decade ago, some of these studies may lack cur-
rency and understanding. Further, studies excluded for employing
nontherapeutic controls [e.g. 60] and qualitative work [e.g. 61] have
added theoretical arguments. In mapping this AT literature, it is
important that we emphasize the many ways of knowing and un-
derstanding experience [62]. We preferred, for this study, to pre-
sent the available direct comparison trials based on recent calls in
the literature for comparison group studies [24].
5. Conclusion
This scoping review located 13 studies where outcomes of
adventure therapy, provided in clinical settings, were directly
compared with other therapeutic conditions. Like other direct
comparison trials [6,29], few significant differences were found to
pinpoint specific ingredients required to produce significant
change. If the person of the client and therapist are responsible for
the lion's share of change [31], future research may abandon the
search for specific ingredients and begin exploring what can lead to
improved outcomes. While studies routinely measuring outcomes
are starting to occur [e.g., 70], researchers could conduct more
patient-focused research to explore the dose-response relationship
[71] finding the connection between outcomes and time spent on
an AT program “to mark a point in treatment at which cases that
have not shown any measurable improvement should be subjected
to clinical review” [71, pp. 163e164]. These methods [65] can help
further explore the variance between therapists and help certain
programs establish plans for continuous quality improvement. By
privileging the AT participant's experience above the model and
engaging influence of the therapeutic relationship, AT practitioners
can systematically monitor outcomes to simply rely on whether or
not the service they are providing is working for each individual
client, not what the service is or how it is defined.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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Table 2
The Specific Ingredients Identified in this Review.
Therapeutic Rational Specific Ingredients
Treatment setting Varying lengths of stay
Varying amounts of time spent in nature
Types of wilderness environments
Indoor vs outdoor settings
Individual focus vs family involvement
Matching treatment to diagnostic criteria
Multiple family groups
Nontraditional role of therapist
The presence of a qualified therapist
Therapeutic ingredients High vs low ropes course elements
Primitive survival skills (i.e., fire making, trap building)
Structuring WT programs based on phases
Family involvement programs
Amount of physical activity
Success and mastery
Rock climbing
Use of metaphor
Letter writing
Experiential education
Journaling
Hiking
Perceived Risk
Social group setting Group problem-solving activities
Interpersonal tasks
Intense social milieu
Social responsibility (i.e., completing day-to-day tasks)
Solo experiences
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