COVID-19: The intersection of outdoor programming, mental health, and risk management

A Conversation Between

Dr. Christine Norton - L.C.S.W. and

Steve Smith – Experiential Consulting, LLC

Introduction: This conversation was spurred by the recognition that outdoor behavioral healthcare programs continue to serve youth and young adults with acute mental health needs in the midst of the COVID-19 global pandemic. Mental health treatment is considered essential, especially in a time of increased vulnerability. Dr. Benjamin Druss, Professor of Public Health at Emory University, recently provided traditional mental health practitioners with guidelines for how to continue operating as safely as possible in the current COVID-19 context. So we thought it would be important to consider the issue within the OBH context. As a risk management consultant and an outdoor behavioral healthcare researcher, we view the issue through different lenses, though we share the same values for protecting clients and staff, and establishing practices for maintaining physical and emotional safety. We realize the complexity of these issues, and want to examine these issues objectively, with client safety and quality programming at the forefront of the conversation.

Christine: Given that outdoor behavioral healthcare (OBH) programs have been deemed essential, it is critical to consider the responsibility of OBH programs, particularly, wilderness therapy programs, to manage risk during the COVID-19 pandemic. Unlike non-therapeutic wilderness programs, many of whom have temporarily closed or postponed programming, many wilderness therapy programs have continued operating to serve the increasing, acute mental health needs of youth and young adults; however, there are concerns about how to protect youth and staff from possible sickness, as well as the responsibility these programs also have in helping flatten the curve. This feels like an important ethical dilemma to discuss from a risk management perspective.

As a wilderness risk management professional, what are some of the key things you think we should consider?

Steve: In the current state of the pandemic, none of the options are really ideal. I work with a lot of (non-therapeutic) programs which have very important missions - leadership, youth development, personal growth, outdoor skills, all the classic reasons why people go on outdoor trips - and I would say that as great as they are, none of those things are worth catching Coronavirus over. It's easy, in many of those cases, to minimize the risk of contagion to students and staff (and help flatten the curve, etc.) by closing down those programs while the pandemic is underway. Many programs are in the process of doing that, or already have. (Note: While this article focused on wilderness therapy programs, other outdoor programs are also up and running right now as essential services, including conservation corps programs working in agricultural / food supply chain projects, or emergency response support).

But in the case of wilderness therapy programs, many of their students are already at risk in their normal lives, or they wouldn't have enrolled in the therapy program to begin with - so it's not as simple to say that by closing down for a while, that this eliminates risk for them. We have just exchanged one risk for another. In other words, there is an argument to be made that the students could be better off in the therapy program (which is classified as essential healthcare, as you mentioned) than sent back home (or elsewhere). This is a complex question and it really comes down to individual programs and individual students rather than a broad answer that uniformly applies. For example, if a student was in a therapy program for purely elective, non-clinical reasons – if they would not be a threat to themselves if they went back home, in other words - that swings their case back towards possibly better off at home. If a therapy program did not have proper protocols in place to adjust their operations to manage the threat of Coronavirus (as best as possible), that swings the equation back to maybe better off at home as well. But if the organization has effective staff, protocols, equipment, and training in place to operate during COVID-19, the students may very well be better off in the program that at home.

Christine: Those are all really good points. The difficult thing is that we are seeing a rise of mental health vulnerability during this pandemic. People who already had pre-existing depression and anxiety may be more at risk because of social isolation. According to Yao (2020), "the COVID-19 epidemic has caused a parallel epidemic of fear, anxiety, and depression. People with mental health conditions could be more substantially influenced by the emotional responses brought on by the COVID-19 epidemic, resulting in relapses or worsening of an already existing mental health condition because of high susceptibility to stress compared with the general population."

The scary thing is that a recent CDC report came out before this pandemic showing that teenage suicide rates have increased exponentially in the past decade, and now these same youth and young adults may be at even greater risk.

Of course, if these youth can be served by community-based mental health, that is almost always the best option, and is recommended by the Substance Abuse and Mental Health Services Administration; however, if youth have acute mental health needs that transcend community-based treatment, they sometimes need to spend time in a hospital or residential or wilderness treatment options.

So, youth and young adults may need wilderness therapy programs more than ever; however, the problem during this pandemic is multi-faceted. There is a rolling admissions process in most wilderness therapy programs in which new clients will enter pre-existing groups. This means new clients who may be infected and asymptomatic. Likewise, some clients come from all over the country, including geographic hot spots for the virus, some of whom are involuntarily transported. The question is how can these programs safely address these risks, in order to serve clients effectively?

Steve: I share your concerns, Christine. This is why therapy programs are being seen as "essential" services and still allowed to operate, even during the pandemic - because, these are essential healthcare services. So, the question then becomes, how to run the programs.

There are some things which well-equipped wilderness therapy programs already have in place, which make them more resilient to COVID-19 than many of their classic open-enrollment outdoor education counterparts may be:

· Therapy programs may have an intake process that includes medical exams and rigorous screening on the front end;

· They may have a team of highly-trained medical personnel on staff already, and first aid kits already stocked with more specialized equipment for frequent health assessments;

· They may have a team on-call 24-hours a day already to oversee and respond to any issues;

· They should have a close relationship already established with secondary layers of support like physician advisors, not to mention therapists on staff already

In short, they were probably better equipped to deal with acute medical issues than many wilderness education programs would normally be.

Some of the adaptations which they are making (or will have to make) include updates to medical screening protocols, intake procedures, ongoing assessment, quarantine plans for any outbreaks, and how to manage the coming and going of field guides, therapists, and visitors to the field - while also managing the safety of their own staff in the process. There's also the piece about communicating the risks to parents, students, staff, and stakeholders, and integrating these pieces into waivers, insurance policies, etc. A lot of change to manage in a very compressed timeframe. I know some programs have also decided that they cannot (or should not) operate during COVID-19, so have decided to hibernate for the time being. I respect these decisions, and hope that these programs are able to rebound and reopen once conditions change.

I have been very impressed by many of my clients and other programs who are working hard to make these adaptations and changes to their policies, procedures, and organizational norms, whether they are currently open or currently hibernating.

Christine: It's interesting to see some of the things that WT programs have in place already that may assist them in dealing with this crisis. I wonder how this will change future risk management and even accreditation practices in the future? I hope that programs will write down and put in place future emergency preparedness plans that account for pandemics, contagion and other disaster scenarios.

I do know that these issues also affect companies that often transport youth in crisis to these types of programs. I've been co-chairing a joint task force on transport with the National Association of Therapeutic Schools and Programs and the Outdoor Behavioral Healthcare Council, and have been asking transport companies about how they are also engaging in safe and ethical practices during this time of pandemic. Some have mentioned standard safety protocols, but in addition have been minimizing transport from contagion hot spots, new intakes and taking precautions to only transport youth who are physically healthy, yet with the lack of testing and the fact that people can be asymptomatic, it seems hard to be certain. However, credible transport and wilderness therapy programs seem committed to following similar procedures that other behavioral healthcare professionals are following.

In your opinion, is there any one thing that these programs could do differently during this difficult time?

Steve: Because I basically eat, drink, and sleep risk management theories and research all the time, my worldview is probably a little different than many people. In my mind, when you solve one risk issue you often create another. For example, we carry pepper spray for bears but are at risk of setting it off on ourselves accidentally. Or, we add seat belts to cars to make people safer, but then they drive more recklessly thinking they're invincible. These elements are very inter-connected and hard to predict with any accuracy - like an ecosystem. And when these factors interact with other factors, new risks can emerge that weren’t there to begin with.

So, based on this, there is not really one thing that I think is the right thing for programs to do, other than perhaps being flexible, learning and adaptive to the changing nature of the situation. How will our approach change, for example, once widespread antibody testing is more readily available? Having the ability to know who has already had COVID-19 may fundamentally affect how we approach things like transport, or student/staff quarantines, practices in the field, etc.

What this pandemic has shown me is how un-resilient our society really is, in many ways. We lack basic healthcare, so many people came into the situation with pre-existing conditions. We lack education, so many people are suspicious of science or government agencies to begin with. We lack strong federal structures of leadership, so each state governor was free in many ways to do whatever they wanted to do, and then mayors of cities in those states went in different directions than their governors. We lack healthcare systems that can absorb sudden influxes of patients all at once. So, while COVID-19 was the perfect storm in terms of its viral nature and impact, the story for me was more about our lack of defenses than the specifics of the virus' offense. Unless we build resilience in those other areas, we will remain vulnerable to future issues even as COVID-19 threats may diminish.

Is there one thing that stands out for you as the best area for the field of practice to focus on for resilience, at this point?

Christine: I agree. We need to focus on building a more resilient society. Even in terms of our need for and reliance on involuntary mental health treatment in general, we see we are in this position because we don't offer much in the way of mental health prevention. Figuring out how to create more access to basic screening and early intervention would certainly help.

As for this pandemic, my only advice is to both wilderness therapy and associated professionals, such as educational consultants, transport companies, etc. is more of an ethical nature. Yet it is advice I would give in normal times when there is no pandemic as well. This advice would be to find ways to balance the fiscal solvency of programs, with clients’ best interest. Too often we see residential programs focus on their census, i.e., how many beds they can fill, and though this can be essential for funding and economic sustainability, if financial decisions are prioritized over client safety, then there will be dire consequences that could shut down a program anyhow. I know that many OBH Council programs are already well aware of this, with some of them turning down revenue to ensure client wellbeing while they adjust their operations during this difficult time.

Finally, much like we are seeing the need to take care of our frontline healthcare workers in this crisis, I would urge WT programs to pay close attention to the physical and emotional health and safety of field staff right now, as much as they do clients. These young people are often the ones with sustained contact with clients, and if there are not protocols or supports in place to make sure they are healthy and safe, the entire intervention is at risk. This is true in both making sure they have been quarantining, don't have a fever, and that they go through a similar health screening coming and going from the field, much like new clients, as well as assessing their mental health, vicarious trauma, and levels of burnout.

I agree that there is so much to consider, and I appreciate the nuanced and complex nature of this dialogue, Steve. So often, we want quick fixes and easy answers, when what we really need is to look carefully at multiple sides of an issue with the best interests of people in the forefront.

Steve: This brings me to my underlying risk management philosophy - that we should not be running away from the negative - injuries, lawsuits, accidents, sickness - we should be running towards the positive - mission delivery, educational outcomes, health and wellness. And if we do that in a values-driven way, we become more resilient as a result. Safety can be seen in the presence of resilience rather than by the absence of sickness, in other words, not just for individuals or even programs, but for the larger society too.

References and Resources

Outdoor Behavioral Healthcare Council COVID-19 Statement

Outdoor Behavioral Healthcare Center

Experiential Consulting, LLC - Risk Management for Outdoor Programs

Patients With Mental Health Disorders in the COVID-19 Epidemic

Center for Disease Control Data Briefs

SAMHSA Reports to Congress

Dr. Christine Lynn Norton received her Ph.D. in Social Work from Loyola University Chicago. She has a Master of Arts in Social Service Administration from the University of Chicago and a Master of Science in Experiential Education from Minnesota State University-Mankato. She is a Licensed Clinical Social Worker and a Board Approved Supervisor in the State of Texas. She has over 25 years of experience working with youth and young adults in a variety of settings including therapeutic wilderness programs, juvenile justice, schools, mentoring and campus support programs. She has taught as adjunct faculty at The University of Denver, Prescott College, and Naropa University. Her areas of practice and research interest and expertise are in positive youth development; innovative interventions in child and adolescent mental health; adventure therapy; outdoor behavioral healthcare; experiential education; foster care support in higher education; and international social work. Dr. Norton is a Research Scientist with the Outdoor Behavioral Healthcare Center and she helped launch Foster Care Alumni Creating Educational Success (FACES) at Texas State. She is the Foster Care Liaison Officer to the Texas Higher Education Coordinating Board, and is the founder of the Foster Care Adventure Therapy Network, an international group of programs and practitioners who utilize adventure therapy with current and former foster care youth and young adults. Dr. Norton is active in study abroad and is also a Fulbright Scholar, having taught adventure therapy in the Department of Civic Education and Leadership at National Taiwan Normal University.

Steve Smith is the founder of Experiential Consulting, LLC, providing risk management support to outdoor programs and schools. He has worked in the outdoor industry for over thirty years, in the field, in the office, in the board room, and in national conference leadership roles, specializing in risk management.

His career has included leadership roles with national organizations including Outward Bound and The Student Conservation Association. Steve served as the Chair of the Wilderness Risk Management Conference (WRMC) for three years (2014 - 2016). He served two terms as a board member for the Northwest Outward Bound School, where he continues to serve on the school's Board of Directors Safety Committee.

He has a master's degree in teaching English, along with years of university-level teaching experience, and earned a Professional in Human Resources (PHR) certification from the Society for Human Resources Management, all of which help him view outdoor education through a variety of educational and administrative lenses.

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