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Posted August 16, 2000

For Woodbury Reports
July 2000 

By Rob Cooley, Ph.D.
Catherine Freer Wilderness Therapy Expeditions

(Rob Cooley earned a Ph.D. in counseling psychology from the University of Oregon in 1979. He specialized in family and adolescent therapy at Oregon's Children's Services Division and in private practice, while taking summers off to run a white-water rafting outfit. In 1988, he combined his outdoor and therapy interests in founding Catherine Freer Wilderness Therapy Expeditions.

(This research and a similar article were published by The International Journal of Wilderness (University of Idaho Wilderness Research Center, Vol.6: 1, April 2000). OBHIC programs which have contributed incident data for this research are Anasazi, Aspen Achievement, Catherine Freer, Red Cliff Ascent, and SUWS.) 

Two years ago the members of OBHIC (the Outdoor Behavioral Healthcare Industry Council) set out to deal with two of the most troublesome arguments against outdoor treatment: that it is not as safe or as effective as traditional indoor psychiatric and residential treatment. 

Traditional therapists and health insurance companies sometimes voice the view that outdoor therapy is, perhaps, a little too much fun, more like a health-promoting summer camp than a serious clinical endeavor. To provide concrete data for this discussion OBHIC is working with the University of Idaho's Wilderness Research Center to produce a broad based, scientifically cutting- edge treatment outcome study. Data collection is under way, and preliminary, results should be available in early 2001. The study will continue to follow OBHIC's graduates for another year, with final study results published in the spring of 2002. 

On the safety side public concern has arisen from extensive media coverage of three tragic deaths in outdoor programs in the last decade. Accurate incident data is a key to weighing wilderness treatment against the risks young people incur in other settings, and in recognizing risk issues and situations so that risk management procedures can be continually improved in outdoor youth programs. It may also help to overcome adverse publicity about tragic and highly publicized incidents, which are not characteristic of the wilderness treatment industry. Parents, referral sources, public land agencies and insurers all have legitimate concerns about the risk levels in the growing wilderness treatment industry. 

There is always some risk in any outdoor program, and no guarantees of complete safety can be made by any responsible program. But there is also risk in any residential program, in school, in sports, and, for that matter, in just getting through the teen years. 

Starting in 1998, the five original OBHIC programs, all from the West, began collecting careful data on their injuries and illnesses, and compiling that data collectively for the five programs. To create a meaningful perspective for this data, I gathered together several years worth of material I had been collecting on accidents and injuries in different types of outdoor activities and in other kinds of activities often engaged in by adolescents. With a good deal of advice and encouragement from other collectors of adolescent injury data, who are as concerned as we are about the risks for teens in the modern world, I was able to translate much of this information into comparable terms, so that the risks of different activities could be directly compared. 

The standard I selected is the rate of incidents per 1,000 person days. This is the standard developed by NOLS (National Outdoor Leadership School) and Outward Bound, and it enables one to make immediate sense out of outdoor program incident data. It is harder to fit school sports injuries (reported per season) and automobile injuries, usually reported as a rate per population per year, into the chosen format, and I had to make several decisions about how to translate from one activity to another. (How many hours a day does a teenager spend in a car? How many hours of sports practice are equivalent to one day in the woods?) Translation errors are my own, but I believe the results fairly accurately reflect reality and are important to all of us in the Woodbury Reports family.

OBHIC's 1998 incident data and my original report (published in The International Journal of Wilderness, University of Idaho, April 2000) suggest that the injury and illness risks of wilderness treatment are well within the bounds of rates for other activities, including ordinary daily living, that we easily accept for our adolescents. Responsible wilderness treatment has less risk of injury than the best summer youth adventure camps (Todd Schimelpfenig, 1996; Drew Leemon, 1999; Outward Bound, 1998.) Downhill skiing is three times as likely to lead to injury as outdoor treatment (Drew Leemon, et al, 1998), and high school football practices produce 18 times as many injuries (Eric Zemper, 1998.) (For detailed information, please refer to the table.) 

Since the advent of modern wilderness treatment programs a dozen or so years ago, no responsible program has experienced a client death. Accidents being accidents, that will almost certainly change eventually. If we assume that the fatality rate for wilderness treatment programs will be about the same as for good adolescent adventure camps (a conservative assumption for several reasons) then the eventual fatality rate would be about the same as for commercial white-water rafting (University of Colorado Business Research Division, 1998), one-third of that for teenagers occupying motor vehicles (National Safety Council, 1998), and about 20 per cent higher than the fatality rate for the average teenager living at home (National Center for Injury Prevention and Control, 1999.) This is not to gainsay the fact that four young people died in three different outdoor treatment programs in the last 10 years; for those three programs, the fatality rate was very high indeed. The three programs were all fairly recent start-ups, and had some other fairly apparent characteristics in common. The lesson here is that referral sources and parents need to be careful about the wilderness programs (as well as other programs) to whom they send children. A little effort should produce a clear picture as to which programs are interested in and sincere about taking responsible steps to manage risk for their clients and staff. 

In 1999, OBHIC programs reported somewhat lower incident rates. This may be a result of more accurate reporting as the programs have become familiar with the reporting standard: an injury or illness is only counted if it interrupts a client or staff member's participation in regular activities for 12 hours or more. (All OBHIC programs collect very detailed incident reports, and separating out the incidents that meet the 12-hour test is not always easy.) It may also be a result of paying more attention to these incidents. Between the 1980s and the mid-1990s, NOLS (the National Outdoor Leadership School), which has been a leader in both collecting and courageously publishing risk incident data, saw a drop of more than 30 per cent in its injury incidents. High school football, which had 41 injury deaths nationally in the seven years from 1982 to 1989, had only 12 in the seven years from 1990 to 1997(Frederick Mueller and Robert Cantu, 1998.) This is apparently due to improved helmets, new rules to protect against head and neck injuries, and an increased concern with serious injuries, including better and more rapidly available treatment. It is certainly OBHIC's hope that increased program awareness of injuries and illnesses, and improved methods of dealing with them, will continue to bring down our incident rate. 

It would be useful to be able to compare injuries and deaths for outdoor programs and indoor residential and psychiatric programs. Surprisingly, it appears that such figures are not even collected. The Hartford Courant, in an excellent series on deaths from restraints, was able to locate only two states that kept figures on fatalities in state-licensed and state-operated programs. I had trouble believing this, so checked it out in my own small, responsible and fairly well organized state, Oregon. Sure enough, no one could tell me; the data simply are not centrally reported anywhere in Oregon, nor even tracked by particular agencies for their own clients. Based on the two states (one was New York) that do track fatalities, a statistician hired by the Courant extrapolated an estimate of 50 to 250 residential treatment deaths nationally per year from restraints alone. (This includes delinquent and developmentally delayed adult populations, but not prison or senior residential programs.) (Eric Weiss and Dave Altimari, October, 1998.) Judging from those figures, it may well be that indoor treatment is more dangerous than outdoor treatment. 

For parents and referral sources, perhaps the best risk comparison is with the risks a child runs while living at home. Comparable injury data are hard to come by, but there are good national statistics on fatality rates by age and cause. The overall injury fatality rate for white 15 to 19 year olds is 54.4 per 100,000 population per year, which translates to 0.0015 per 1,000 days, or 1.5 deaths in 1 million days (National Center for Injury Prevention and Control, 1999.) This means that if you have an average adolescent living in your home, their risk of having a fatal accident is about 80 percent what it would be if they were in a NOLS program or, as well as we can estimate, an OBHIC wilderness treatment program. For a troubled teenager, incurring many additional risk factors (driving more often at night and with carloads of other adolescents, using drugs and hanging out with others who use, driving and swimming while drinking or using drugs, and on and on) the chances of serious injury or death while living at home are almost certainly higher than while participating in wilderness treatment. 

There is no way we can keep our children completely safe from injury and death. If we want to keep them as safe as possible we should certainly not let them drive, or even get into a motor vehicle during their teen years. But we don't aim for the impossible goal of complete safety. Instead, humans intuitively calculate levels of risk for activities that balance our fears and our intuitive assessment of risk, against our perceptions of the value or the necessity of those activities, and we develop a risk acceptance level for each activity. People wearing seat belts drive faster on average; on rainy nights, most drivers slow down. (Gerald Wilde, Target Risk, 1994.) Everyone knows that high school football produces a lot of injuries and some deaths; gymnastics and modern-style cheerleading appear, from fragmentary reports, to be at least as risky as football, for deaths and paralysis, and soccer is not far behind. Swimming and boating produce many fatalities every year. But we don't want our children to grow up in gauze-wrapped, sterile test tubes: life is always risky, and indeed rewards the (carefully) adventurous. 

Wilde, a professor who specializes in risk analysis, argues that humans are excellent intuitive calculators of risk as long as we have enough accurate data as a basis for our judgments. On this view, we may miss opportunities by over-responding to occasional sensational reports of incidents (grizzly bear maulings in Alaska, murders in New York City for those of us who live out West and don't hear much else about New York), or take unnecessary risks because we have not heard about important incidents. (Most white water canoeing and rafting deaths are of relative amateurs, who have basic skills and love the sport but have not yet heard and seen enough accidents to be aware of the range and degree of dangers.) I hope this article will serve to extend and clarify the relevant databases for all of us who work with the outdoor treatment field, and for those parents who entrust their adolescent children to us for the growth and healing that outdoor adventure and treatment can provide. 

A final set of figures may assist with clarifying this particular database. 

Based on OBHIC's 1998 data, if one child were to spend 1,000 days in the field with an OBHIC program, a little less than three years, he or she could expect to be injured a little more than once, be ill enough to have to skip daily activities for a full day a little less than once, and would be taken to a doctor's office or hospital for treatment of an injury or illness a little more than once. As a parent who has so far survived three adolescents (one to go!), this rate feels to me like about what we've dealt with given healthy, very active kids. From a program perspective, a 50-day program with 7 adolescents in a group could expect a group to have about one injury, one illness, and one evacuation every third 50-day outing.