What is Outdoor Behavioral Healthcare & How does it relate to Fitness?

Outdoor Behavioral Healthcare, Adventure Wilderness Programs

& Physical Training Principles. Danielle Chevalier. Revised May 2019.

Introduction:

It is no secret that being physically active improves both mental and physical health. Science supports the notion. (Kohl & Murray, 2012) (Buckworth & Dishman, 2002). Outdoor recreation scholars and Eco psychologists have also proven that exercising in nature further enhances the benefits (Brymer, Davids, & Mallabon, 2013) (Gladwell, Brown, Wood, Sandercock, & Barton, 2013). Sometimes called adventure therapy, wilderness therapy or outdoor behavioral healthcare (OBH), these programs use the outdoors as therapy. Recognizing nature’s depth of benefits, the fitness industry has also been taking training outdoors (Spears, 2017) (Twist & Shiels, 2011) (Webster, 2007). But in turn, how is the outdoor recreation field furthered by the latest findings in exercise science? For example, adventure therapy that offers climbing instruction. Here clients learn the skills to climb as part of a holistic healing process that has mental as well as social benefits. Consider also climbing gyms, like a bridge to both worlds: fitness & outdoor. They are becoming popular and rock climbers do recognize the necessity for training. The need for personal trainers to be educated on the training needs and the language of climbing to better serve them is growing (Phillips, Sassaman, & Smoliga, 2012). Shouldn’t OBH facilitators be educated on the language and state of the art of health and fitness? While OBH programs are designed to provide a physical challenge to produce positive health benefits (Werhan & Groff, 2005), drawing the line between too much and too little physical challenge is complicated. Physical training principles should not be an afterthought left to the personal preference of individual adventure therapy facilitators. Someone in the OBH team should have a base knowledge of training principles, fitness components, and exercise science so that programs reduce their incidences of injury. This article attempts to give a basic understanding of training principles and to answer the question: How do wilderness therapy programs incorporate these physical training principles?

Nature provides unique opportunities for physical activity by providing what has been termed by wilderness adventure researchers Eric Brymer, Keith Davids, and Liz Mallabon, (2013), as environmental affordances. Each different element, a climbable feature or a varied surface and such are affordances: opportunities for physical action that can be programmed to have more and less challenge. Each action is “an expression that can improve physical and or mental health” (p.193). Assessing whether a physical challenge is optimum requires having some language and criteria to do so. As will be shown here, physical training principles that can easily be applied to OBH are: Volume, Specificity, Progressive Overload, and Reversibility.

The concurrent model for adventure therapy acknowledges four components to a program: Nature, the Active Self, the Group, and Reflection (Russell, 2012). Inherent in the component of Active Selfis that participants are physically challenged. The other relevant component is the Group. The Group teaches pacing, encouragement, support and respecting participants learning comfort zones. Participants may have low levels of base strength at the beginning of a program, but working together as a team, everyone expands their skills and builds self-efficacy. This paper will show how programs do and don’t heed health and fitness professional modalities. First going over some background of OBH and of physical training principles and the components of fitness. Second, addressing metabolic pathways for using energy as it relates to OBH standards. Lastly looking at the kinetic chain, how we can prevent pain, reduce injury and how the OBH team balances challenge and skill.

Background/Sharing Interdisciplinary Language:

Outdoor adventure recreation professionals may focus more or less on a spectrum from either pure recreation provider, as educator, as facilitator for personal growth development, or as therapeutic facilitator (Dawson & Russell, 2012). Learning by doing is an important tenet on every part of that spectrum and “adventure-based activities and programs operate from the model of experiential learning” (Moote & Wodarski, 1997, p. 5). Dr John McCullagh and Associate Professor Peter Martin showed commonalities between physical educators and outdoor educators. Both teach experiential knowledge gained from physical activity and both set up, encourage, and facilitate lifelong learning. Outdoor educators in addition to everything that physical educators do, teach about and contend with the environment (Martin & McCullagh, 2011). What then is expected of the adventure therapy professional, who falls at the end of this spectrum scale? Adventure therapy practitioners use adventure activities explicitly as treatment intervention for behavioral, social or psychological problems (Jelalian, Mehlenbeck, Lloyd-Richardson, Birmaher, & Wing, 2006). The outdoor educator is expected to teach physical education in addition to environmental education, but in therapeutic recreation the licensed OBH provider is expected to have mental health professionals on their team as well (Blanchette, 2010).

The Association for Experiential Education (AEE), have developed guidelines for practitioners across the spectrum states : adventure programs “use physical activity to teach responsibility, cooperation, relationships, social skills, and resiliency” (aee.org/tapg-practioner-guidelinesfor adventure activities, 2017). Priest and Gass also clarified competency areas and specific technical skills for leadership in adventure programming, dividing activity instruction into the categories of backcountry travel, rock-climbing, mountaineering, challenge/ropes course + group initiation, caving, paddling, bicycling, and cross-country skiing. In each of these categories, except backcountry travel, instructors are expected to “assess clients overall physical fitness and psychological readiness for participation” (Priest & Gass, 1997, pp. 77-83). If they are expected to assess fitness levels, then they should have the necessary fitness concepts and terms to do so appropriately, even if it adds an extra layer of demands for the OBH team. By understanding the principles of volume, specificity, progressive overload, and reversibility we can see how OBH does challenge safely, though it may be more intuitive, and the terminology is not necessarily a part of the adventure therapy dialect.

Volumeis the total whole of frequency, intensity, type, and length of time an activity is performed. The purpose is a measure to help gauge needed recovery times, and decide what activities should follow. Specificity is the idea that if you practice something, anything, you will improve your capacity to continue doing so. Using hiking as an example, you improve your hiking ability by practicing to hike. Reversibility, sometimes referred to as the use it or lose it principle, shows us that over time if you do not practice certain skills, though you may cognitively understand how to, you lose the physical capacity to do them. For example, you may have biked 20 miles a day in the summer, now it’s winter and you still know how to ride a bike, but you do not have the physical stamina do so in a day. If you haven’t kept up or haven’t been doing another activity, or combination of activities that is similarly taxing, then demanding as much physically will cause damage. Unless you’ve been keeping your muscles strong through biking (specificity) or using the same muscle groups in other activities, it’s not possible to do so safely. Progressive Overload is that we gradually increase the challenge so that we have maximum gains in strength, endurance, and flexibility without doing more harm than good. OBH facilitators use these principles in planning without necessarily having the same language.

It’s also important to understand the fitness components, each of which can be harmed or helped in adventure activities. The fitness components of health are cardiovascular endurance, muscular strength, muscular endurance, flexibility, and body composition. Cardiovascular endurance is the capacity for your heart to move blood through your body efficiently. Muscular strength refers to your onetime maximum capability for a muscle (or group). Muscular endurance is the ability, (not necessarily at max capacity) over time. Muscles work best together when they are optimally flexible. A muscle that is too tight cannot function properly. This is the component of flexibility. Body composition refers to the ratio of muscle mass to fat mass. Both are necessary but it’s important to have more muscle mass for health. There are also fitness components of skill that should be built on within a foundation of health fitness components (American Council on Execerise, 2010). They are agility, speed, power, & balance. Adventure activities require fitness skills, but it is dangerous to push physical limits without understanding foundational health components and how they impact the capacity for fitness skills.

OBH standards make sure participants are properly fueled for recovery.

There are three metabolic pathways that your working muscles use to access energy to function. They are: creatine phosphate and glycogen stored in muscles (both anaerobic) respectively used for efforts under 30 seconds and efforts lasting between 30sec and 2 min., and circulating blood from the cardiovascular system (aerobic) that increases its demands for any effort over 2 min in length (Ed: Bryant, C.D., & Green, D.J., 2011). Different activities have varying ratios of demand type. For example, climbing requires relatively more anaerobic capacity than other activities (Phillips, Sassaman, & Smoliga, 2012). Regardless, all activities require refilling stores, which means getting the necessary food in your body. Fueling for recovery is critical. As is screening for potential heart attack risk factors and carefully designing progression of programs so the cardiorespiratory system itself builds strength without being overwhelmed by demands. Licensed OBH organizations are required to have participants get medical exams prior to program start, to provide weekly nurse check-ups while on trips, and to have any medical problems referred out to a physician (DeMille, Comart, & Tucker, 2014). Screenings for cardio risk factors are used in OBH by physicians who perform pre-participation medical exams for participants (Green, 2015).

State standards for OBH mandate that programs have: “1. Individualized treatment plans 2. Regular medical check-ups. 3. Supervision by licensed mental health professionals 4. Safety Procedures. 5. Nutrition requirements” (Blanchette, 2010, p. 43). Having these mandates in place helps assure participants are physically challenged appropriately and get the proper nourishment so their bodies can get stronger. In Utah the licensed OBH is required to provide a minimum of 3000 kcal, with additional increase depending on increase in volume per day and weather/climate stress. Underweight participants get extra protein (DeMille, Comart, & Tucker, 2014). Steven DeMille, Casey Comart, and Anita Tucker looked at how OBH participants’ body composition changed over the course of treatment programs. The researchers were able to show gains in muscle mass for most participants. By measuring muscles mass before, during, and at the end of treatment programs a standard for healthy outcomes in OBH can be set. In their study they looked at more than 2000 OBH participants in different organizations, the average treatment lasting 73 days, the main activity intervention being trekking for an average of 4 or 5 days a week and 3 to 10 miles a trek. The group who were underweight at the start of the program, had a mean gain of 7.5 pounds muscle mass (DeMille, Comart, & Tucker, 2014). Their article highlights some potential ways for monitoring that could be used to prevent overtraining in OBH.

The Importance of Matching Challenge to Ability and of Having an OBH Teammate Understand Kinetic Chain Stability

The human body works best when complimentary muscles and muscle groups work together and are optimally both strong and flexible. Without adhering to these principles, trauma and pain to the muscular skeletal system will increase. Most often lower back, knee or shoulder and neck pain (American Council on Exercise, 2010). If an activity instructor (or someone else on the OBH team) does not know this, there is an increased risk of doing more physical harm. Understanding the kinetic chain basics of hip/lower back stability, shoulder girdle stability, balance of strength and flexibility in muscle groups helps to prevent injuries. The kinetic chain foundation goes from bottom to top, beginning at the feet, then to ankle and all the way to the top of the head. If one joint, muscle group, or level in the chain is off then those that follow will be set off proper course (Ed: Bryant, C.D., & Green, D.J., 2011). There is an optimum where the body can be performing at maximum effort without having muscular skeletal damage and ensuing pain. Kinetic chain stability refers mainly to the core base of strength around the hips, where the gluteus muscles and thighs appropriately support the skeletal body and to the core base of strength at the shoulder girdle, where the mid and upper back muscles appropriately strengthened, set a foundation for the surrounding smaller muscle groups. Mobility refers to the ability for a joint to move through its appropriate range. If certain muscles are too tight then mobility is hindered, increasing the risk of injury. This is kinetic chain stability and mobility (Ed: Bryant, C.D., & Green, D.J., 2011) (American Council on Exercise, 2010). Every individual body is unique. An individual in their own body can best gauge their own limits. But if someone on the OBH team is not aware that having one muscle group over trained in comparison to another will increase the risks of pain and injury how are they able to prevent or even talk about pain with participants? Without this basic kinetic chain knowledge OBH can over push clients causing more pain.

An article looking at therapeutic outcomes of adventure education experiences for military veterans published in Ecopsychology stated that overall higher challenge levels seems to maximize results (Ewert, 2014, p. 161). With an effort to maximize challenge how does OBH balance pushing physical limits without causing injuries? It’s done by having a team approach for program design, by matching client needs to activities and by being careful to use risk and challenge appropriately. Programs are designed around a team from many disciplines including sport specific instructors, wilderness medical staff and mental health professionals. Shooter, Sibthorp, & Paisley designed a model for adventure programs that puts the organization’s mission and goals at the center and where the necessary skills required to safely implement a program are filled by a variety of employees from different backgrounds. They divide necessary competencies into the categories of technical skills, interpersonal skills, and judgment skills (Shooter, Sibthorp, & Paisley, 2009, p. 70). Not all employees need to understand the full scope of anatomy and physiology in order to have physically challenging courses. It can still be a part of the core principles through the use of varied staff.

Expeditions are often tailored to weakest member in moment and a graduated increase in pack weight for example or using hiking poles if necessary to take the weight of hips (Nathanson, Young, & Young, 2015, p. 57). Another way that OBH protects participants from physical trauma is by using pre-participation medical exams and partnering with wilderness medicine professionals. Wilderness medicine shows it’s important to match fitness to skill. The key of pre-participation exams (PPE) is to determine between actual fitness level and expected demands and to educate the individual or agency if necessary (Campbell, et al., 2015, p. 41). Pre-participation medical exams can be used less as a screening tool and more as communication and education tools.

OBH chooses an activity based on client assessment, needs and proper sequencing to maximize benefits. AEE guidelines for adventure programming highlight two important criteria that should always apply to activity choice. It should be based on 1. The limitation to practitioner’s inherent ability in the activity and 2. The application of choice of activity must be matched with client assessment and needs (aee.org/tapg-practioner-guidelinesfor adventure activities, 2017). This relates back to the particular competencies for specific activities. For example, in either rock climbing or paddling there are sport specific skills and abilities that the facilitator can only use as intervention if they are knowledgeable and competent themselves. In addressing client needs OBH uses challenge and risk strategically. Two key ways that they do this is through what is termed challenge by choice and by properly sequencing to build on strength skills (Ewert, 2014, p. 161) (Blanchette, 2010, pp. 74-76) (Moote & Wodarski, 1997, p. 6). Challenge by choice recognizes that people have different comfort levels in terms of learning and beginning new activities. If people are pushed outside of their comfort zones they can learn and begin new behaviors. However, if they are pushed too far outside their comfort zone, beyond their learning zone, into areas where they have too much fear, then more harm will come than good. Challenge by choice allows the individual to decide where their comfort levels stand, and sequencing allows for safe progressive overload. This is also a great opportunity to teach the participant strategies for learning and creating their own boundaries, listening to their body’s needs and challenging themselves without pushing too far.

OBH also uses the principle of flow in program planning and implementation (Tucker, Widmer, Faddis, & Randolph, 2016). Flow happens when maximum challenge is appropriately matched with skill level.

In a study on adventure therapy used in conjunction with cognitive behavioral therapy, compared to the control group, adventure therapy showed an increase in locus of control which increased levels of physical activity (Jelalian, Mehlenbeck, Lloyd-Richardson, Birmaher, & Wing, 2006, p. 32). This is compatible with the American Council on Exercise views on getting people active (American Council on Execerise, 2010). Leaders with experience can see how fitness levels impact ability for skill development. However, having certain measurement tools allows them to check their intuition and back up what they might be sensing. One particular tool is ratings of perceived exertion (RPE). Instructors can use it as education and as a way of measuring for safety. It can be used to assess participants’ physical challenge intensity levels and as a way to open up the conversation about flow, challenge by choice, or mindful awareness of the body’s senses. Three levels of physiological intensity are correlated with personal discomfort levels as it relates to how hard a person is physically challenging themselves. The three levels: movement, discomfort tolerance and noxious pain avoidance (Buckworth & Dishman, 2002, p. 269), are then applied to a 10 or 12 point scale (American Council on Execerise, 2010) whereby the active individual and activity facilitator can moderate by staying within a certain range.

Conclusion:

In OBH it important to “design programs with the amount of daily physical challenge required to produce positive health” (Werhan & Groff, 2005, p. 26). OBH can do this by partnering with wilderness medicine physicians and by aligning with health and fitness professionals. The American Council on Exercise (ACE) personal training guidelines are consistent with OBH values. They are:

1. Create Mastery. This means working with clients where they are, acknowledging their baseline strength and building up. For OBH it can mean focusing on AEE building on strengths and sequencing. 2. Provide Consistent and Clear Feedback. For OBH: in a metanalysis on adventure program evaluation a recommendation as an area to focus on in future process studies, it was suggested that “adventure programs increase the amount and quality of feedback that is vital to the experiential learning process” (Hattie, 1997, p.75). 3.Include client in all aspects of program design. This could be possible with more formal feedback-informed treatment program design “FIT” (Dobud, 2017) (Russell, 2017). 4. Empower with perception of control over their own participation and actually give client control. OBH challenge by choice even within captive participant situations. 5. Engage client ownership and involvement in the program by teaching self-sufficiency and autonomy to facilitate intrinsic motivation.

OBH fuels for recovery, works with the group by making pacing to the ‘weakest’ a priority, plans for proper sequencing, and uses a strength-based approach to instruction. Although pain and repetitive stress injuries are addressed using onsite medical staff visits and the pre-participation exam, someone on the team should understand kinetic chain stability and mobility to properly assess fitness levels, realize how specific activities impact pain, and to further prevent overuse injuries.

Bibliography

aee.org/tapg-practioner-guidelinesfor adventure activities. (2017, October 26). Retrieved from aee.org: www.aee.org/tapg-practioner-guidelinesfor adventure activities

American Council on Execerise. (2010). ACE personal trainer manual. SanDiego,CA: American Council on Exercise.

Blanchette, A. W. (2010, Sept 14). The clinical theory and practice of outdoor behavioral healthcare. Regent University. Virginia Beach,VA.

Brymer, E., Davids, K., & Mallabon, L. (2013). Understanding the psychological health and well-being benefits of physical activity in nature: an ecological dynamics analysis. Ecopsychology, 189-197.

Buckworth, J., & Dishman, R. K. (2002). Exercise psychology. Champaign, Il: Human Kinetics.

Campbell, A. D., Davis, C., Paterson, R., Cushing, T. A., Ng, P., Peterson, C. S., . . . McIntosh, S. E. (2015). Preparticipation evaluation for climbing sports. Wilderness & Environmental Medicine, 40-46.

Caulkins, M. C., White, D. D., & Russell, K. C. (2006). The role of physical exercise in wilderness therapy for troubled adolescent women. Journal of Experiential Education, 18-37.

Dawson, C. P., & Russell, K. C. (2012). Wilderness experience programs: a state-of-the knowledge summery. USDA Forest Service Proceedings.

DeMille, S. M., Comart, C., & Tucker, A. (2014). Body composition changes in an outdoor behavioral healthcare program. Ecopsycology, 174-182.

Ed: Bryant, C.D., & Green, D.J. (2011). ACE'S essentials of exercise science for fitness professionals. SanDiego, CA: American Council on Exercise.

Ewert, A. (2014). Military veterans and the use of adventure education experiences in natural environments for theraputic outcomes. Ecopsychology, 155-164 .

Gladwell, V. F., Brown, D. K., Wood, C., Sandercock, G. R., & Barton, J. L. (2013). The great outdoors:how a green exercise environment can benefit all. Extreme Physiology & Medicine, 2:3,1-7.

Green, G. A. (2015). Setting, structure, and timing of the preparticipation examination: the wilderness adventure consultation. Wilderness & Environmental Medicine, 4-9.

Jelalian, E., Mehlenbeck, R., Lloyd-Richardson, E. E., Birmaher, V., & Wing, R. R. (2006). 'Adventure therapy' combined with cognitive-behavioral treatment for overweight adolescents. International Journal of Obesity, 31-39.

Kohl, H. W., & Murray, T. D. (2012). Foundations of physical activity and public health. Windsor, ON: Human Kinetics.

Martin, P., & McCullagh, J. (2011). Physical education & outdoor education:complementary but discrete disciplines. Asia-Pacific Journal of Health, Sport and Physical Education, 67-78.

Moote, G. T., & Wodarski, J. S. (1997). The aquisition of life skills through adventure-based activities and programs: a review of the literature. Adolescence, 143-177.

Nathanson, A. T., Young, J. J., & Young, C. (2015). Pre-particpation medical evaluation for adventure and wilderness watersports. Wilderness & Environmental Medicine, 55-62.

Phillips, K. C., Sassaman, J. M., & Smoliga, J. M. (2012). Optimizing rock climbing performance through sport-specific strength and conditioning. Strength & Conditioning Journal, 1-18.