Media's unfair attack on wilderness therapy

How a powerful adolescent mental health treatment is being destroyed by social media influencers and journalists desperate for a story

In the last twenty years, an adolescent mental health treatment called “wilderness therapy” has evolved in the public imagination from a treatment for out of control and manipulative teenagers to one in which innocent children are victimized by a greedy and unregulated mental health treatment mill.

One need only compare the 2005 BBC reality-show Brat Camp with Netflix’s 2023 documentary Hell Camp to see this evolution. Whereas Brat Camp is driven by its depiction of, well, brats, getting what they deserve, Hell Camp is driven by its depiction of misunderstood kids sent to a traumatic and dangerous boot camp that – if it doesn’t kill them first – just makes them worse. If only the story were so simple.

While both depictions flatten this story into a laughable cartoon, Brat Camp is pure entertainment – reality television – and essentially benign. But Hell Camp, while silly, is a documentary that seeks to be taken seriously, and situates itself within a movement to change teenage mental health treatment that’s frequently, if not largely, malignant. After illustrating traumatic and sometimes deadly stories about long-defunct treatment programs, Hell Camp turns the volume up on our anxiety with a stark warning: “This year, thousands of children will take part in a wilderness therapy camp.” As shocked as viewers may be after watching this documentary, they might be just as shocked to hear that nowhere close to thousands of children attended U.S.-based wilderness therapy programs in 2023 (the year the documentary was released), and of those, exactly zero will experience a legally operating program in the U.S. that is anything like those shown in the documentary.

Hell Camp’s salacious narrative has found similar appeal at the NY Times, Rolling Stone, The Guardian, and USA Today, all of which have published empathy-laden features about teens traumatized by wilderness therapy programs in the Teen Treatment Industry, or “TTI”. Like the Netflix documentary, after discussing abusive and deadly wilderness therapy programs from the 1980s, 90s, and early 2000s, the articles seamlessly transition to highlighting the more recent experiences of (primarily) teen girls who have gone viral discussing their accounts of abuse and neglect at TTI programs on social media.

One such account is Paris Hilton's, who metamorphosed from rich bad girl (notorious for her one-liner, “That’s hot,” on the 2003 Fox show The Simple Life) to the effective Queen Bee of anti-TTI activists. Following in the tracks of Ms. Hilton, others achieve their own notoriety by becoming influencer-cum-activists on that veritable hotbed of adolescent activism: TikTok. While some frame their efforts as being about reform of the TTI, just a little digging shows that these efforts amount to the demand: End TTI – We don’t want mental health treatment that would challenge us to change. Indeed, on the “Safe Treatment Facilities” webpage of TTI-survivors advocacy group Breaking Code Silence, users are directed to a cheeky message that reads, “404: The page you are looking for cannot be found because there are no safe TTI facilities,” which sits above a hyperlink that encourages users to “Explore Safer Treatment Alternatives.”

Having worked with at-risk youth in wilderness therapy and residential mental health treatment for nearly a decade, it seems that in trying to end TTI, Breaking Code Silence, Paris Hilton, and other activists are largely trying to avoid accountability, not seek it. Like most people, I am not in support of more abusive and deadly wilderness boot camps, which rightly went out of business. But what these activists would have you believe is that programs like these are still operating all over the country, and if you aren’t careful your struggling kids will also get abused, become traumatized, and possibly die. The truth is quite different, actually.

What is “Wilderness Therapy”, really?

Towards the end of my tenure as a guide in wilderness therapy (WT), too-online kids would frequently arrive terrified that they were now attending an abusive military style program in which they would be subjected to being “scared straight”. For some participants it could take several days to relax and realize that isn’t what we were doing. From an outside perspective, I can understand why WT is so easy to misunderstand – WT might mean anything from Netflix’s Hell Camp documentary to walking through a park and appreciating nature.

To address these definitional issues and distinguish themselves from a history of abusive wilderness boot camps, in the mid-90s a group of WT programs banded together to form the “Outdoor Behavioral Healthcare Council”, (OBH Council) which works to ensure best practices and conduct evidence-based research. Research on OBH member programs defines wilderness therapy, “as an intervention in which clients are immersed in wilderness for extended periods and engage in individual and group therapeutic work that focuses on self-reflection, coping mechanisms, interpersonal communication, physical and mental challenges, identity development, and skill development.” This sort of WT was designed for adolescents whose behaviors are a concern and where parental conversations, at-home solutions, and other traditional therapy treatments have not worked. Problem behaviors include school refusal, assaulting family members, self-harm, risky sexual behaviors, and drug use, among others. At this point, the experiential nature of WT is ideally suited to deliver natural and logical consequences that can effectively stop these behaviors.

The WT staff who work directly with program participants, aside from being highly trained in backcountry living and therapeutic skills, are some of the most interesting and inspiring people I’ve ever worked with (these are people who choose to work 8 to 16 days at a time in the backcountry with at-risk youth). Besides having a significant number of staff who are successful in a conventional way (Ivy League graduates, people with significant higher education experience, etc.) the majority of staff were ambitious and successful in ways that matter little to hiring managers but that matter a lot in building relationships with adolescents. Many staff were former clients of the programs and believed deeply in their effectiveness. Some were therapists who wanted to do work that was more experiential and impactful. Some staff were retired ranchers and farmers from big families who were adept at teaching skills like building fires and backcountry living. And many staff were idealistic young people who had thru-hiked the Appalachian Trail or something similarly difficult and simply believed in the power of the outdoors to heal and liked working with kids. What all these different people had in common, for those who stuck it out for more than a few shifts, was that they were willing and able to build relationships with highly challenging kids, in very difficult physical conditions.

The job of staff was to facilitate the program, which lasts 1-3 months for each participant, and consists of two interventions that work in tandem: the wilderness intervention, and the therapy intervention. Staff guide participants on expeditions in which they hike from site-to-site in a backcountry area, and each week participants do therapeutic work during their free time and days off from hiking. While there is the hard work of being on an expedition – living outside in all kinds of weather, hiking, and cooking as a group – the point isn’t any of those things; the point is what all these things evoke in the students which we are then able to discuss. Students are taught tools like an I-feel statement which they can use at any time to tell the group how they are feeling. With the help of staff, groups also come up with their own rules for what is expected and a code of conduct: who has what chores, what proper manners in the group are, and what the group’s consequences are for improper behavior. Staff enforce the boundaries of the group and give consequences when group norms are violated. Staff and students run therapeutic groups on concepts like accountability, freedom and responsibility, wellness, shame, the dynamics of healthy and unhealthy relationships, and meditation and mindfulness. Individual therapy varies greatly, but assignments during the week are often creative and experiential. For example, an anxious student who doesn’t like their voice to be heard might be given an assignment to lead the group for the day and reflect on what emotions they felt as they were leading. Or a student who is mourning the loss of a loved one might be given an assignment called an empty chair, in which they imagine their loved one sitting in front of them in an empty chair and tell them all the things they wish they could still say if they were present. Students are also given assignments related to backcountry living skills: from simple things like tracking their water and food intake, to carving a wooden spoon they can eat with, to making fires with a traditional bow-drill. These assignments are frequently the most helpful for behavioral observations and as tools for reflection. As students live their lives week-to-week doing therapy in the backcountry, staff write notes on students and share them with the therapist, who then conducts talk therapy sessions with each student once a week to reflect on what happened and set goals for the upcoming week.

Throughout this process, students see in themselves signs of concrete progress. Even after one week of being outside, students have provided for themselves in significant ways: they made a spoon, they stayed warm at night, they set up a shelter, some have begun to confront their fear of the dark or insects. After a few weeks, students see even more significant gains: they can start a fire without a match (some can do this in seconds), they know how to stay comfortable in varied weather conditions, they know how to make a nutritious meal over a fire. After 2-3 months living outdoors, students can not only start a fire, they can do it easily and teach others how to do it; they can carve spoons, bowls, rings, flutes, guitars, chess pieces; they can lead the preparation of a whole meal for a group; they can mentor other students on the nuances of using their gear to stay comfortable.

And students grow in significant social and emotional ways as well. After one week, students have learned how to describe their emotions in basic ways with a group and have learned they are capable of asking for help with many things they weren’t able to do. After just a few weeks, students have experienced, communicated and worked through many frustrations related to backcountry living and with other people; many students have experienced confrontation in the group and worked through it with both staff and students; and students have built trust in others as they depend on the group for many of their needs. After 2-3 months, students have communicated difficult and vulnerable things to the group, staff, and their parents, and students are able to better manage confrontation after dealing with the many dramas of small-group backcountry living.

We would often say that students are ready to leave when they are comfortable in the program, and for that to occur you have to change a lot. After noticeable changes from week to week, by the end of their stay, students are hardly recognizable to themselves and most are deeply proud that they accomplished something few others have. And profoundly, most students have confronted, even if just a little bit and whether they realize it or not, whatever they are most afraid of. While this has been my experience, the research backs it up.

Wilderness Therapy Effectiveness and Safety

A meta-analysis of post-treatment outcomes of nearly 2,400 WT participants in OBH council-accredited programs showed significant improvement across 6 target constructs including: self-esteem (g = 0.49), locus of control (g = 0.55), behavioral observations (g = 0.75), personal effectiveness (g = 0.46), clinical measures (g = 0.50) and interpersonal measures (g = 0.54). The size of these effects is considered medium, which is typical of behavioral health interventions, but medium effects are remarkable given that wilderness therapy is designed for adolescents who haven’t responded to other treatments. Indeed, another study found that adolescents who attended WT improved 2.75 times as much as adolescents who received at-home medication management and psychiatric care. WT has also proven to be an effective treatment for a wide range of presenting symptoms and across demographic categories. Male and female adolescents with anxiety, depression, oppositional behaviors, and addiction to substances reported significant improvements. And parents reported bigger gains of their children’s progress than their children did – gains that were maintained a year-and-a-half after they left WT. In an ironic twist, adolescent girls and “sexual minorities” (those who identify as something other than male or female) show the biggest improvements in WT even as they are the most likely to protest the treatment on social media. In fact, females are much more likely to experience significant improvement than males and one study showed their distress scores reduced 49% more than male clients while participating in WT. But despite such massive improvements relative to males, females are much less likely to participate in WT, comprising 30% or less of participants in over 20 studies I reviewed.

In my experience, WT is a more popular choice for families of adolescent boys than girls for three reasons. First, girls generally exhibit less overtly defiant behavior than boys, which is often a trigger for sending a child to treatment. Second, due to the popular association of WT with “boot camps” (as is evident from the aforementioned framing by credulous media outlets), even after the treatment has been explained, parents have to overcome a lot of guilt to send their kids to a program. For many, the idea of sending their “little girl” to a program associated with a boot camp is simply too much. Third, and perhaps most significant, parents of adolescent girls know the reality of relational retribution all too well. A common motif of end TTI activism is relating the betrayal they felt that their parents chose to send them to a program. Parents must contend with the guilt and shame of being blamed for their child’s problems on social media, and this goes for anyone working with these children. At one of the programs I worked at, therapists and staff working with girls were doxxed by some former students. While I enjoyed working with girls because of the comparatively rich emotional processing, I was frequently more relaxed with boys because they were less likely to play victim and get revenge. Like parents, treatment programs are liable to hold girls less accountable because they fear this indirect retribution.

Adolescent activists against WT frequently discuss the many dangers they say amount to abuse and neglect: the cold at night, the insects and animals, the bad weather, the hiking, the hard ground you sleep on. But according to a state of Utah database on teen treatment program safety (Utah is where WT began and has the largest number of evidence-based WT programs), WT programs are safe places for adolescents, especially compared to the alternatives. Of the nine WT programs in the database, seven had “rule violations” (these are incidents that can be reported by anyone when a rule is broken), and just two surpassed the state average of two violations per program. And of all WT rule violations, the vast majority didn’t violate a rule other than failing to report on time. This database supports my own experience: the two WT companies I worked for were the best-managed, most professional, and safest form of away-from-home behavioral health treatment I’ve worked in. For example, in WT we always had sight or sound supervision, unlike other residential and inpatient facilities where I worked. This meant if a participant was going to the bathroom, they had to call their name every five seconds so that we knew they were safe; and participants at risk of harming themselves had to be within an arms-length of an employee at all times. In part we were so scrupulous because we had to be – we knew that if we couldn’t keep kids safe, then we would quickly lose credibility. Mostly though, we were excellent at safety because of our standards for communication and feedback. We were in the business of teaching healthy communication, and we practiced health communication in everything we did: daily constructive feedback on performance was expected, not optional.

The death of WT and its’ consequences

I applaud the WT programs and staff that have chosen to work with girls, because they tried their best despite the costs. Currently the only WT program in Utah operating close to capacity is, not surprisingly, an all-boys program. Most other WT programs are likely to disappear from the teen mental health treatment landscape as support rapidly erodes (1),(2). In the last year, 5 of the 9 WT programs operating in Utah have gone out of business. With just four remaining WT programs the state is well below its 10-year average of 11 licensed programs.

Like any good moral panic, End TTI activists are looking for a scapegoat to blame their problems rather than trying to create meaningful change. WT is an excellent choice because it superficially resembles old-school boot camps like those depicted in Hell Camp. But also, WT is being scapegoated because it has proven to be highly effective in treating anxious and defiant social-media-addicted teenagers. Rebellious teens bent on doing as they please understandably want to end a treatment that would really challenge them. Unfortunately, pandering to the demands of “End TTI” advocacy has had bad effects beyond killing WT to the much bigger domain of away-from-home mental health treatment as a whole.

In response to the emotional testimony of activists like Paris Hilton, the Utah Senate passed legislation in 2021 (roughly concurrent with the climax of our Covid fever dream when we considered whether abolishing the police makes sense) that added several new rules for programs. This package of legislation includes some helpful new guidelines (like increasing visits to programs by regulators and requiring more stringent rules for background checks), but was in significant respects a ham-handed effort to assuage the guilt and shame of legislators who couldn’t believe child abuse happened in Utah. In tandem with the new law, the relationship between mental health programs and the state went from facilitative to punitive. With the 2021 bill, many things that coaches require of their high school football players and teachers require of their students are illegal in Utah mental health treatment centers. WT programs aren’t allowed, for example, to require that a student unpack and re-pack their backpack – a so-called “pack drill” – as this constitutes a repetitive movement and a “cruel, severe, unusual, or unnecessary practice on a child.” Telling a child that they can’t eat for any period of time, like in the middle of an activity, is also considered “cruel, severe, unusual …” because it is “depriving the child of a meal.” Even parents’ tried and true “time-out” falls under the umbrella of cruel and severe because it withholds “personal interaction, emotional response, or stimulation.” (In WT, we could suggest a time-out, but we couldn’t enforce it if a child wanted to come back to the group.) With average kids these practices are helpful, but with kids that openly defy the rules, they are necessary.

The most damaging new restriction from the 2021 legislation though, is that any form of pain compliance is now considered cruel and severe. At the programs I worked at, we used pain compliance in one instance only: when in a physical hold with a student who is a danger to themselves or others, and who is continuing to fight back against the staff while in the hold. When this happened, we would hyperextend their wrist forward so that if their wrist is pointing upwards the hand is pointing downwards in what is sometimes called a “gooseneck”. At the levels we used it, this was a medically safe but painful position that was very effective in calming down students who were trying to hurt us. The gooseneck hold resulted in shorter hold times and fewer injuries to students and staff. Without interventions that utilize pain compliance, WT programs (who aren’t authorized to utilize chemical or mechanical restraints) can’t manage precisely who they are intended for: the most aggressive, treatment-resistant kids.

At the WT program where I worked post-2021, the ultimate result of the legislation was the closest I’ve ever come in a mental health setting to the proverbial “inmates running the asylum”. Even while fewer students were entering our program and we were taking “easier” kids than in the past, participants were able to get away with things they had never been able to before; the kind of chaos the parents of these kids were used to seeing at home became manifest in our program. While former students on social media were alleging abuse by WT, ironically, I began to think of my work as a form of abuse for employees (something the state of Utah doesn’t appear to track). Several of my coworkers and friends were injured for weeks and even months by holds that went on far longer than they would have in the past. Employees were routinely verbally and physically abused, cussed at, and spit on. But in a strange twist, even when employees had it within their power to offer consequences for bad and abusive behavior, after Utah’s 2021 legislation they often didn’t. By some combination of idealism, nihilism, and Stockholm Syndrome, I think employees came to believe that our students were victims for being put into wilderness therapy (a message the students, the state of Utah, social media, and mass media were screaming at us from the mountaintops) and if it made the kids feel better to abuse someone, then they were willing to be the object of abuse. As one would expect, our staff turnover became higher year-after-year, which in turn led to more chaos, worse care for our students, and a more dangerous program for employees. In a testament to the power of WT, I still think our students grew and healed from managing the hardships and emotions of life in the wilderness, but our program was much less effective than in years past because by law, we were far more limited in creating a culture where the adults were in charge.

A long-time girl’s therapist at my last program who left during this chaotic time remarked in one of our last conversations, “The kids are winning.” Her comment stuck with me because she was very egalitarian in her approach, and I never thought she would frame our work as a competition. But I guess I was naïve and in part her effectiveness was that she actually knew our work was in some sense a game. And she was right, the kids are winning. The most tangible losers are the WT programs and the clients they would have served. While insurance has driven the rise of 30-day stabilization programs, they are no replacement for the kind of intervention WT could offer a family that has exhausted all other options with their teenager. Indeed, WT was designed for precisely the child who wouldn’t be helped by a 30-day program. Many of the kids who would have gone to WT then, will likely end up in inpatient 24/7 lock-down facilities, the criminal justice system, or worse. But the biggest losers in my view are the programs and kids that serve those who never would have gone to WT because of the high price tag. The residential programs who serve low- and middle-class teenagers now operate in an environment that is hostile to their work as part of the “TTI” and they have to deal, at least in Utah, with a short-sighted bill that severely limits their ability to create a safe and effective program culture.

As the Breaking Code Silence webpage says, “There are no safe teen treatment facilities.” This is untrue, but it will be more credible if the activists behind the webpage continue to have their way. These anxious teens and social media influencers have crafted a narrative in which they are the victims of a greedy and abusive teen-treatment industry and if you don’t agree with their demands then you’re also an abuser. It’s worked for the last decade or so, but we will have to get over being called scary names if we want to stop hearing about the teen mental health crisis every day.