Catherine Freer Wilderness Therapy Programs

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Outcome Research
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Catherine Freer is one of the best researched adolescent therapy programs in the U.S., and that research clearly shows that our clients are benefiting substantially from their treatment at Freer.

We have conducted 24 research projects which have guided our therapy work over the years. Collectively, they have established that Freer's approach to adolescent therapy is very effective. Learn more about our research:

Does Wilderness Therapy Work? Does it Last

Lifting the Fog of Depression

Solving Substance Abuse

Getting Motivated to Give Up Substance Abuse

A Short Term Treatment for Incipient Character Disorders

Family Functioning After Wilderness Therapy

Strong Therapeutic Relationships

Limits on Research with Adolescent Treatment Programs

List of Catherine Freer Research

Research Results Summary
Two large studies we conducted jointly with other wilderness treatment programs using good community norms for comparison, show that wilderness treatment at the high quality OBHRC programs is effective in returning most adolescents to functioning within or near community standards, and that they continue to get better during the year following treatment. (Please see references No. 17 and 18.) A qualitative follow-up study indicates that two to three years after wilderness treatment 83 percent of clients are "doing better" according to their parents and themselves, while only 17 percent are "still struggling." (Ref. 19.)

At Freer and OBHRC we have conducted four studies of depression, enough to be confident that Freer wilderness therapy is effective in dealing with it. The large 2006 OBHRC study of substance abuse and client changes in readiness to make changes in their use, along with OBHRC follow-up interviews (2004) and three smaller questionnaires used by Freer, strongly indicate that Freer is effective in reducing substance abuse by its clients. Dr. Jeff Clark's excellent research strongly supports the Freer program's ability to assist teenagers suffering from incipient character disorders. An OBHRC study showed positive results from treatment of anxiety and adolescent stress. Two studies included tests on the strength of the therapeutic alliance of kids with their field staff, and indicated that this, which is considered to be a crucial element of successful treatment, is a strong component of wilderness therapy. Three Freer studies of family changes following treatment of one of their children are very positive in terms of improved performance by the child after returning home and improved family relationships.


Does Wilderness Therapy Work? Does it Last?
The Outdoor Behavioral Healthcare Research Cooperative's (OBHRC), a cooperative of wilderness treatment programs of which Catherine Freer is a member, completed the first big outcome study on wilderness therapy using the Youth Outcome Questionnaire (YOQ) with a sample of 858 kids and their families from nine programs over a full year.

The YOQ is a simple but well-researched and solid therapeutic outcome test on which higher scores indicate greater behavioral/mental health disorder. Average scores for adolescents admitted to a psychiatric hospital are about 100; average score for teens in outpatient treatment are 78; the average community adolescent score is 23. The upper limit of the normal community range is 46. Our results showed that:

In other words, contrary to a common opinion about brief, intense treatments, the therapeutic and behavioral gains of wilderness treatment were sustained over 12 months. (No. 18.)

For a follow-up study published in 2004, after these clients were two to three years out of their OBHRC treatment, 88 of them were called to ask how they were doing, using a structured interview process via telephone. (No. 19.) Some of the important results:

OBHRC is now planning a five-year follow-up study on the same group to see how the kids and their families have fared since our last interviews with them.


Lifting the Fog of Depression
Freer's first outcome research effort was a doctoral dissertation by Steven Wall in 1992 No. 1.) Steve wanted to know whether Freer was effective in treating depression. Using the Beck Depression Inventory, he found that:

While Steve's answer had to be tentative due to its small client number, three subsequent studies have also explored depression and, taken together, have come to a solid "yes."

A 2002 Ph.D. dissertation by Dr. Jeff Clark (No. 8), using the MACI (Millon) and a sample of 70 Freer clients, showed that the four Millon scales dealing with depression all showed significant decreases in depressive feelings and symptoms over the three weeks of a Freer trek, and in each case the effect size was large. ("Statistical significance" indicates how likely it is that the observed results were produced by chance; .02 indicates the results could be a product of chance two out of a hundred times. "Effect size" indicates how large the observed change was: an effect size of 0.5 to 1.0 is considered moderate, 1.0 to 2.0 is large, and over 2.0 is very large.) Those Millon scales, and their effect sizes, were Doleful/Depressive, 1.29; Depressive Affect, 1.19; Suicidal Tendency, 2.07, and Self-Devaluation, 1.53.

In 2004 Amy Nortrom, a Freer wilderness therapist, finished her excellent M.A. dissertation on depression treatment at Freer. (No. 11.) Amy used both numerical test data to establish that the clients were improving from a statistical point of view, and her own very good clinical skills to give beautiful qualitative descriptions of how several of those clients worked with their depression (and other issues) on treks on which she was their therapist.

Amy's qualitative descriptions of her clients' changes over their three week treks give meaning to the statistical changes. Her work with one of her clients, "Richard," is described below.

One of Amy Nortrom's clients in her dissertation study, whom she calls Richard (not his real name), she describes as defensively non-communicative in his first week. He was both depressed and addicted to marijuana. "In the second week, Richard was able to identify that he felt empty and hopeless and lacked passion in his life.... Richard struggled to connect with himself on a deeper emotional level and often remained numb and unexpressive... He stated, 'I want to feel more like a part of my family; like I know what's going on in my parents' lives and they know what's going on in mine.'" Richard and his family decided together that he should stay with the program for its four-week Extended Expedition, and by the end of his seventh week his depression score had dropped significantly, he was feeling much better about himself and more open, and he was able to go home and stay sober and feel good about managing his life and his relationships more successfully, instead of just watching them happen to him.

A large-scale research project published by Keith Russell in 2006 (see below) drew 872 clients from five OBHRC programs, including Freer. The depression part of that study showed that of 79 clients who entered wilderness treatment as "extremely severely" or "severely" depressed, 45 (57 percent) were less or no longer depressed after treatment. (No. 20c.)

That left one question open. Depression is a mental health problem that can fluctuate from month to month or even hourly at times. Not surprising that our kids felt good after living outdoors for several weeks. How about months later; were they still feeling better? The OBHIC clients in Dr. Russell's study answered the same questions about depression six months later, and their scores showed that the girls were feeling substantially less depressed than when they left Freer, though the result did not quite reach statistical significance. The boys were feeling even more improved, and the change in their scores was statistically significant.

So we can feel confident that wilderness therapy at Freer can alleviate depression for most adolescents, and that for most of them the results are lasting. This is intuitively obvious to those of us who work as therapists and guides for Freer, because so much of what happens for young people living outdoors is exactly what is prescribed for treatment: plenty of long muscle exercise, interesting activities and social interactions, exciting events when possible, successfully taking care of one's daily needs while also getting dependable support from people who care about you, healthy food, good sleep at more or less regular hours. We watch one or more kids emerge from the fog of depression on almost every trek. And we reinforce the natural effects of living outdoors with caring people by teaching our clients what it is that is helping them get well, and how they can continue that when they get back home. We pass on that same information to their parents in our weekly telephone contacts and our all-day end-of-trek meetings, so that they can help their children maintain those gains.


Solving Substance Abuse
About 70 percent of Freer's clients abuse alcohol and drugs to some extent. The Outdoor Behavioral Healthcare Research Cooperative (OBHRC) studied this issue in another extensive research program with results published in 2006 by Dr. Keith Russell, who directed the study. (No. 20d.) It established that 77 percent of the OBHRC study's clients had either substance abuse diagnoses or dual diagnoses in mental health as well as in substance abuse (49 percent.) The remaining 23 percent had mental health diagnoses only. A long and well constructed questionnaire, the Personal Experience Inventory (PEI) indicated that:

OBHRC clinical follow-up information nicely supplement the six-month PEI results. Eighty-eight of the kids and families from OBHRC's first big study, in 2002, were called two to three years later by trained interviewers and invited to participate in a structured interview about how they were doing. The substance abuse portion of that interview, published in 2004, showed these results for the 71 clients who did have substance abuse problems when they started treatment: (No. 19.)

Freer's very first in-house study, done in 1994, shed some early light on long-term CD outcomes for us. Sue Parrish, one of our wilderness therapists, had a baby and retired from the field. She pulled a sample of 47 trek files from Freer's first four years and managed to reach 40 of the families for structured telephone interviews with parents and kids. Their overall reports were similar to those we have gotten in more recent research, though not quite as good in the long term results. Our interviewees reported moderate to significant improvement at one month (79 percent), dropping a little at six months (62 percent), then rising again, to 67 percent at one year and 74 percent long term (1 ½ to 4 years.) Other scores followed that pattern with approximately the same scores except for getting over alcohol and drug abuse or dependence. There, the scores were 51 percent at six months, 43 percent at one year and 55 percent long term. We considered 25 of the kids at risk for addiction; they rated themselves only a little higher on their recoveries, except for a 75 percent doing better long term. Eight of them (32 percent) were drug free at one year, but three of those had attended another residential treatment program in the meantime. Those who were abusing drugs seriously before trek, or were considered already addicted, did less well. Half of them (7) went through additional residential treatment, and only 22 percent saw themselves as "significantly" improved in the long term (when they were interviewed.) Those clients who had also run away from home over night at least once prior to trek rated their alcohol and drug success even lower.

Those results are pretty much in keeping with those of standard indoor residential CD treatment, but they were quite a bit worse than our clients' progress in other areas, and we determined to improve in that area. We hired a very experienced CD clinical director from a Chicago program, and tasked him with teaching us all how to do a better job of CD therapy. Rick succeeded in that, and we have been a much better program for his efforts and results.


Getting Motivated to Give Up Substance Abuse
Getting substance abusers motivated to change their habit is one of the big challenges of treatment. Wilderness treatment does pretty well at this, according to another test in the same 2006 OBHRC study. (No. 20c.) It showed that entering wilderness treatment, 73 percent of our clients either had no interest in changing their behavior, or, though they might be thinking about it, were "reluctant" to take any action. The rest had stopped trying to ignore the problem and were beginning to participate in efforts to change. By the end of their wilderness treatment, none of our clients were still in the first phase ("uninvolved") and just nine percent were in the second phase ("reluctant.") The other 90 percent were either in the "active anticipation" phase or, having worked through the issues and decided to quit or seriously reduce their use, had gone on to the final phase, "maintenance" of their decisions.) There was some backsliding at the six month follow-up, but of the 229 clients who filled out this questionnaire at six months, 182 fit the "participation/maintenance" profiles (79 percent) while only 21 percent fit the "reluctant" profile, and none were "uninvolved."


A Short Term Treatment for Incipient Character Disorders
Another Freer research result that we feel confident about, due to the excellence of the research even though the result is quite surprising, is Dr. Jeff Clark's conclusion that Freer's therapy work is the only short term residential program described in the research literature that successfully treats some of the deep-seated character disorders. (No. 8.) (We would probably not be successful with pre-sociopathic issues, and partly for that reason we do not accept clients with those problems.) These problems are normally very difficult to treat, but adolescents are more able than adults to recover from them, Mother Nature provides exactly the kind of emotionally and judgmentally neutral environment these young people need, and our staff provide the right blend of caring and trained therapeutic objectivity to recognize these disorders and to work skillfully with them. In his thesis, Dr. Clark said that "the effect sizes of WT (meaning Freer's Wilderness Treatment) were impressive, particularly considering the short-term nature of the treatment program." Large effects were achieved in too many areas to list here; some were the depression related scales, mentioned above; a few of the others were Eating Dysfunctions, 4.40; Impulsive Propensity, 1.05; Identity Diffusion, 2.34; Body Disapproval, 1.16; Egocentric/Narcissistic, 0.92; Oppositional, 1.28, and Borderline Tendency, 1.59. Jeff closes with two thoughts. "Because the prognosis for treating personality disorders is generally poor, and becomes increasingly so as the individual matures, it is critical that we identify effective treatments and intervene as early as possible;" (p. 76), and "The process of self-discovery is inherently therapeutic in that the self, as the instrument of one's realized and unrealized potential, contains not only the psychic nutrients necessary for healing and growth, 'but the seeds of an individual's growth'" (Samuels, quoted in Clark, pp. 75-6.) This is a particularly tragic problem for adolescents when they fail to deal successfully with incipient character problems in their teens because when the self is shattered or in serious disarray, self realization cannot occur and life becomes ever more difficult and meaningless.


Family Functioning After Wilderness Therapy
For our staff and our families, one of the most satisfying outcomes of Freer treatment is the families' nearly universal experience of much improved and more pleasant relationships with their returning children, closely related to the kids' improved behavior at home and in the community and steadier emotional lives. Much of this change is because the children come home determined to make better lives for themselves and to appreciate and work with their families, while they have also learned a good deal about themselves and matured from the experiences of hard, challenging work taking care of themselves and learning new skills. The kids' part is what most of our research has been aimed at. But their success at home, or at boarding schools after Freer, also depends very substantially on what their parents have learned about them and about family life, and what they have decided to do to improve family life and their children's future lives.

Freer has done three outcome studies to try to understand how family life can change after wilderness therapy for the kids, and what factors lead to those changes.

In 2000 Jackie Cupples, with assistance from Ciel Sanders (a wilderness guide and a therapist,) working with Rob Cooley, a psychologist and the program director, wrote up a one-year study of a pilot questionnaire we had developed to try to get at these questions. (No. 6.) In particular, we worked out some questions about elements of family life that we thought might improve and could serve as gauges to improved communication, understanding and positive effort among family members. These were questions about how often the family at dinner together, how much time parents spent with the returned child in out-of-home activities or in evenings at home together, how much the child helped with chores, and so on. In addition, we had more common questions about the kids' behavior at home and in the community, and their self-management and emotions. What we found was that at two months after the program our graduates, as rated by their parents, had improved substantially on all of our measures, but especially on the child performance ones. At one year after treatment, the answers overall averaged solid maintenance of those gains, but with little average change. However, child performance ratings generally continued to go up, while family interaction measures back-slid a little.

A very heartening response was that, at four weeks after treatment, 80 percent of the kids, and 73 percent of their parents/families were involved in out-patient treatment, and after one year 65 percent of the parents still were, while the participation of our graduates in out-patient programs had risen to 90 percent.

Taking that as a good start, we added more questions and more families (124 responded to the two-month questionnaire) and Nevin Harper, Ph.D., and his doctoral program supervisor, Keith Russell, Ph.D. kindly analyzed the results statistically and wrote them up. (No. 13.) The results were about the same, though, with the statistics emphasizing that. At two months the kids improved on all measures, but with statistical significance on only one of the "Family Function" questions, while improving on about six of the "Adolescent Behavior" questions and two of the "Mental Health" ones. On one family questioning, family arguments, both boys and girls actually argued more with their parents - so be prepared for some warm discussions when they come home! Those results were well maintained at 12 months, though family time together was statistically down some, while two performance measures were up some. (Please see adjoining Table.)

Dr. Harper rounded out his exploration of family change due to wilderness treatment with his Ph.D. dissertation, which used a family evaluation test at Freer and another OBHIC program. (No. 14.) The test failed to generate much in the way of concrete results, perhaps, as Dr. Harper suggests, because it looks for airy constructs that somehow miss the real changes that often take place. Dr. Harper's dissertation is an informed, thoughtful discussion of the nature and role of family and family work in adolescent treatment.

At Freer, our therapy supervisors and field staff are compiling a practical list of family changes we have observed in recent years, as a next step toward understanding what kinds of changes do occur, how they help the families' children, and how we can assist in bringing them about.


Strong Therapeutic Relationships
Perhaps the reason our clients made such gains in wanting to change their lives, and then indeed very much improving them, is to be found in a fourth test the kids filled out for Nevin Harper's dissertation study and Keith Russell's substance abuse study. The WAI and the GTAS both measure the strength of the child/therapist relationship. At graduation, the children most commonly endorsed four items (Russell):

It looks as though time in the beauty and peace of wilderness settings, growing physically strong and increasingly competent in outdoor living skills, is only one aspect of wilderness treatment. The other, and perhaps the one most essential to the healing process, is the strong, trusting therapeutic relationship between the kids and the staff.


Limits on Research with Adolescent Treatment Programs
Because the Catherine Freer program is dedicated first of all to the best interests of its clients, we have not been able to run the kind of experiments where half the clients at random are assigned to a group that gets no treatment of six months. That "gold standard" makes sense for new drugs, but not for children in serious trouble. So we have settled for gold standard client respect and "silver standard" research, which compares our clients with established norms for large numbers of adolescents with similar problems or treatments, as well as with teenagers living presumed trouble-free lives in their own communities. We have also done some qualitative (non-numerical data) research and developed some questionnaires on our own.

While not perfect research, it has been solid, ethical research and by its volume, and repeated studies in some areas such as depression and substance abuse, provides a solid basis for evaluating the overall effectiveness of the Catherine Freer program, and what it does well.

The most important problem with research that lacks a control group is that we don't know how well the kinds of kids who get treatment at Freer might have done had they gotten a different treatment, or no organized treatment at all. Unfortunately, there are "relatively few studies on adolescent substance-abuse treatment," (Russell, 2007), and even fewer of those are on residential treatment. Such studies can at least give a comparative idea of what works best, though, of course, it's important to be sure the clients are similar before drawing conclusions.



Catherine Freer Research Studies
  1. Wall, Steven, Ph.D. 1993. The Effects of a Wilderness Survival School on Adolescent Depression Scores. Ph.D. dissertation.
  2. Parrish, Sue, M.S. 1994. Summary of Follow-up Study for CFWTE. Internal study conducted by Freer, structured interviews by telephone.

  3. Doherty, Thomas, Ph.D. 1995. Using Primitive Skills to Enhance a Therapeutic Wilderness Experience. Independent study thesis.

  4. Rongner, Kris, L.M.S.W.1996. Follow up to Parrish study, using revised questionnaire; structured interviews by telephone.

  5. Taylor, Mark, 1999. Wilderness Therapy: An Experiential Study. Analysis of a Freer trek.

  6. Cupples, Jackie, M.S. 2000. Internal pilot study by Freer, using a questionnaire for two month and 12 month follow-up on family and community issues.

  7. Heywood, Maria, M.S. 2001. The Effect of Wilderness Therapy on the Self-concept of Adolescents. M.S. dissertation.

  8. Clark, Jeff, Ph.D. 2002 dissertation. Published with M.Marmol, Robert Cooley and Kathleen Gathercoal. The effects of wilderness therapy on the clinical concerns (on Axes I,II and IV) of troubled adolescents. Journal of Experiential Education, 2004.

  9. Gerston, Chris, M.S. 2004. Wilderness Therapy: an Intervention Towards Elevating Readiness to Change. M.S. Dissertation.

  10. Grossman, Cindy, Ph.D. 2004. To Have Tomorrow: A Case Study in Outdoor Behavioral Healthcare. Doctoral dissertation, based on qualitative analysis of a Freer trek.

  11. Nortrom, Amy, M.A. 2004. The efficacy of wilderness therapy in the treatment of adolescent depression. M.A. dissertation.

  12. Vissell, Rami, Ph.D. 2005. Effects of Wilderness Therapy on Youth at Risk's Concept of Self and Other. Doctoral dissertation.

  13. Harper, Nevin, Ph.D., Keith Russell, Rob Cooley and Jackie Cupples. 2007. An Exploratory Case Study of Adolescent Wilderness Therapy, Family Functioning and the Maintenance of Change. Child and Youth Care Forum, (36: 11l-129.)

  14. Harper, Nevin, Ph.D. Dissertation, 2007. A study of family change following wilderness therapy at Freer and another OBHIC program.

  15. Ganapol, David, M.S. 2008. The Transformative Effects of a Three-week Adventure Therapy Program with Adolescents: an Exploration of Trauma and Resiliency. M.S. dissertation.
Freer Research in Cooperation with OBHRC
  1. Russell, Keith, Ph.D. (1999.) Theoretical Basis and Reported Outcomes of Wilderness Therapy. (Unpublished doctoral dissertation.)

  2. Russell, Keith, Ph.D. 2001. Assessment of Treatment Outcomes in Outdoor Behavioral Healthcare. (Four participating OBHRC programs.) Child and Youth Care Forum, 2003.

  3. Russell, Keith, Ph.D. 2002. Longitudinal Assessment of Treatment Outcomes in Outdoor Behavioral Healthcare. (Nine participating OBHRC programs.)

  4. Russell, Keith, Ph.D. 2004. Two Years Later: A Qualitative Assessment of Youth Well-Being and the Role of Aftercare in Outdoor Behavioral Healthcare Treatment. (Eight participating OBHRC programs.) Child and Youth Care Forum, 2005.

  5. Russell, Keith, Ph.D. 2006. Examining Substance Abuse Frequency and Depressive Symptom Outcome in a Sample of Outdoor Behavioral Healthcare Participants. (Five participating OBHRC programs.)
    • Stages of change. URICA scale of readiness to change.
    • Therapeutic alliance between adolescents and field staff. GTAS scale.
    • Measures of depression, anxiety and stress using the DASS.
    • Substance use frequency and related personal, social and family issues, using the PEI (Personal Experience Inventory.)
  6. Harper, Nevin, and Keith Russell. Family Involvement and Outcome in Adolescent Wilderness Treatment. Journal of Child and Family Welfare.
Other Sources Referred To

Rohde, Paul, Ph.D., Peter M. Lewinsohn, Ph.D., et al. Natural Course of Alcohol Use Disorders from Adolescence to Young Adulthood. 2001. Journal of the American Academy of Child and Adolescent Psychiatry, 40:1.

Rohde, Paul, Peter M. Lewinsohn et al. Psychosocial Functioning of Adults Who Experienced Substance Use Disorders as Adolescents. 2007. Psychology of Addictive Behaviors, Vol. 21, No. 2, 155-164.

Russell, Keith, Ph.D. 2007. Adolescent Substance-use Treatment: Service Deliver, Research on Effectiveness, and Emerging Treatment Alternatives. Journal of Groups in Addiction and Recovery, Vol. 2 (2-4).