outdoor adventure camps for young adults and...

Outdoor Adventure Camps for Young Adults and Adults with Mental Illness An evaluation of YMCA Victoria’s Journey to Strength Program

A/Prof Sue Cotton, Principal Research Fellow

Ms Felicity Butselaar Centre of Youth Mental Health, The University of Melbourne and Orygen Youth Health Research Centre

Evaluation of the Journey to Strength Program

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Summary

Individuals with mental illness are likely to have ongoing impairments in functioning and social participation throughout their lives. Alternative treatment models such as group outdoor adventure programs can encourage greater social engagement and increase overall functioning. The aim of this project was to evaluate an outdoor adventure camping program for young adults and adults with mental illness; the YMCA Victoria’s Journey to Strength program. This program was developed by YMCA Victoria in partnership with Sport and Recreation Victoria, and mental health service agencies. The Centre for Youth Mental Health, University of Melbourne and Orygen Youth Health Research Centre were commissioned to evaluate the camping program. 108 individuals from mental health services across the state of Victoria participated in a total of 12 camps. Five of these camps targeted young people between the ages of 18-25 years of age. Seven of these camps were run for adults from the age of 26 years upwards. Participants were assessed at baseline (2 weeks prior the camp), end of camp, and 4 weeks following the camp on a range of variables including self-esteem, mastery, and social connectedness. Quality of life was assessed at baseline and 4 weeks post-camp. Participants demonstrated significant improvements in mastery, self-esteem and social connectedness from baseline to end of the camp; however, these improvements were not sustained by the 4-week follow-up. We have demonstrated that utilizing the expertise of mental health services and a community recreation provider can benefit individuals experiencing mental illness. More research is required with respect to how to sustain these benefits over the longer term.


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Acknowledgements

This is an evaluation of the impact of the YMCA Victoria’s Journey to Strength camping program for individuals with mental illness. The report was conducted by A/Prof Sue Cotton and Ms Felicity Butselaar, the Centre for Youth Mental Health and Orygen Youth Health Research Centre. The evaluation was conducted in conjunction with YMCA Victoria, Sport and Recreation Victoria, and local mental health service agencies.

There are several people and organisations that must be thanked for their support for this evaluation project. First, the camping program and evaluation was financially supported by the Sports and Recreation Victoria, the Department for Victorian Communities, the State Government of Victoria. Second, YMCA Victoria must be acknowledged for committing to designing and building a program that enhances that camping sector’s capacity to meet the needs of our broader community. Third, thanks goes to Liz Leorke, Project Director, who developed the model and approached the entire project with much passion, creativity and open mindedness. Fourth, we acknowledge the contributions from the range of people and organisations that supported the development of the project with their participation on the Advisory Council. Advisory Council members included:

• David Strickland DPCD - SRV • Pat O’Leary DPCD – SRV, then Integrated Mental Health Service, Royal

Children’s Hospital • Bernadette Pound Mental Health & Drugs Division, Department Human

Services • David Mithen Maine Connection • Sue Cotton Orygen Youth Health Research Centre • Liz Leorke YMCA Victoria • Ann Nicholson YMCA Victoria • David Pethrick Australian Camps Association • Melissa Finlayson DPCD – SRV • Isabell Collins VIMIAC • Marg Brooks St Lukes • Hans Van Der Graff Mind Australia

Fifth, we would like to acknowledge the enormous contributions from the staff from the range of agencies who partnered with YMCA Victoria to get each camping program ‘off the ground’. Partner agencies included:

• St Lukes Bendigo • Maine Connection • Mind Australia • St Vincent’s Victorian Transcultural Psychiatry Unit • Aspire Warrnambool • Centrecare • Peninsula Support Services • Maroondah CCU • Sacred Heart Mission • Orygen Youth Health


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• North East Health • Prahran Mission • Bendigo Health • Ramsay Health • Headspace Barwon • Eastern CAMHS

Sixth, A/Prof Sue Cotton was supported by the Ronald Phillip Griffith Fellowship, Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne. Seventh, thanks to Vivienne Pearson, Diana Maud, Janine Ward, Christina Phassouliotis and Felicity Butselaar from the Centre of Youth Mental Health and Orygen Youth Health Research Centre with their assistance in collecting data. Finally, and perhaps most importantly, we must acknowledge all the participants who so willingly took part in the program and the evaluation process. In many cases these individuals stepped completely out of their ‘comfort zone’. Their contribution ultimately determined the success of the project.


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Table of Contents

Summary 2

Acknowledgements 3

Table of Contents 5

Introduction 7

Materials and Methods 9

Participants 9

Measures 9

The Camping Model 10

Procedures 12

Data Analysis 13

Results 14

Sample Characteristics 14

Participant Flow 15

Outcomes 16

Qualitative 19

Discussion 20

Limitations 21

Implications 22

Appendices 23

I – Demographics Part 1 (Contact Details) for STEPS and HORIZONS 23

II – Demographics Part II 24

III - Rosenberg Self-Esteem Scale 25

IV - Pearlin Mastery Scale 26


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V - Social Connectedness Scale – Revised 27

VI - Social Avoidance and Distress Scale 28

VII - World Health Organization Quality of Life Scale (WHOQoL-Bref) 29

VIII – Final Questions 33

IX – Camp Evaluation Questionnaire 34

References 38


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Introduction

Advances in psychopharmacology improve symptom outcomes for

individuals with mental illness; however, functioning and social participation can

still remain impaired. Social isolation is also common in individuals with mental

illness, and can be associated with poorer mental and physical health in the

longer term (1).

Alternative models such as outdoor adventure and camping programs,

which encourage social and practical engagement and increase functioning,

provide promise as adjunct to traditional therapeutic processes (2). Adventure

therapy has been used as a therapeutic medium in treating clients with mental

illness since the early 1900’s (3); it has been used for individuals with a range of

mental health issues including addiction (4), youth delinquency (5), anxiety (6),

depression (6-7), schizophrenia (8), bipolar disorder (8), and those with chronic

psychiatric illness (9-10).

Adventure therapy comprises a therapeutic process that promotes

positive change. “Adventure therapy is any intentional, facilitated use of

adventure tools and techniques to guide personal change towards desired

therapeutic goals” (p.87) (11). Camping programs are one type of adventure

therapy. The philosophy behind camping programs is “learning by doing” (12).

Camp participants are provided with multiple challenging opportunities that

may facilitate therapeutic growth (12). Intervention elements include social

engagement, building trust, goal setting, providing consistent feedback and

support, and designing challenging situations (13). A diverse range of camping

activities may be provided such as ropes courses, surfing, mountain bike riding,

and personal growth activities.

Adventure therapy uses the group modality as the primary arena for

change. The adventure component allows clients to engage in appropriate risk

taking behaviours; whilst the group context more closely approximates social

situations that may be encountered outside the program – underlying the

premise that skills learned in this way may be generalized beyond the program

setting (14).

The efficacy of adventure therapy, particularly with regard to young

people, is evident both empirically and anecdotally. In a meta-analysis of 43

studies, it was concluded that “adolescents who participate in adventure therapy

are better off than 62% who do not participate” (p. 40) (2). In addition,

adventure therapy programs significantly increase participants’ self-esteem, self-

confidence, and a shift towards an internal locus of control (15-17). Adventure

therapy may be most effective for participants who are withdrawn and have

difficulty being close to others (3). Being within a group setting can be

particularly useful for facilitating social skills and broadening social networks

(17). Importantly also, improvements in psychiatric symptoms such as anxiety

and depression have also been reported after participation in such programs


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(10). Such factors are likely to have positive influences on rehabilitation

outcomes (18).

There are a number of methodological issues associated with the

evaluation of adventure therapy programs including the variance in the camp

programs themselves, small sample sizes, the lack of control groups and absence

of standardised assessment tools. Further, it is difficult to find existing studies

evaluating the effectiveness of adventure therapy programs delivered in a

camping format for individuals with mental illness.

Following a 2002 review, Sport and Recreation Victoria (SRV)

acknowledged the need to address the access inequities experienced by people

with mental illness to community run camping and outdoor recreation

opportunities. Working with YMCA Victoria, SRV initiated and funded the

development of the Mental Health Access & Participation and Industry

Mentoring Project, now re-titled ‘Journey to Strength’ (19). YMCA Victoria,

government representatives, local mental health agencies and community

providers were involved with the planning and development of a four-day

camping program with the aim of enabling participants to develop a positive

identity, improve their social competencies & broaden supportive relationships.

Camp activities were selected to provide positive, challenging, supportive and

meaningful experiences for participants.

The aim of this report was to summarise the results of the evaluation of

the camping program. It was hypothesized that over the course of the camp and

at 4-week follow-up, participation in the program would improve result in: (i)

higher self-esteem and mastery; (ii) improved social and occupational

functioning; (iii) reduced social withdrawal/isolation by encouraging peer

support, self-esteem and confidence; and (iv) enhanced quality of life (QoL).


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Material and Methods

Participants

Clients from nine mental health services across the state of Victoria,

Australia, participated in a total of 12 camps. These camps were run between

December 2007 and January 2011. Five of these camps were for young people

and adults between the ages of 18 and 25 years of age, known as the “STEPS”

camps. Seven of the twelve camps were run for adults with mental illness aged

from 26 years onwards. These later camps were known as the “HORIZONS”

camps. Whilst the “STEPS” and “HORIZONS” camps were essentially targeting

different age groups; the planning and implementation process, however, was

very similar for each (19).

Inclusion criteria for participation in the camps included a stable mental

state, and no individual risk of harm to self or to others. The participant was also

required to be motivated to participate in the camping program.

Measures

The Centre of Youth Mental Health and Orygen Youth Health Research

Centre (OYHRC) were commissioned by YMCA Victoria and SRV to conduct an

evaluation of the planned camping program. The evaluation had two goals: (i) to

determine the impact of participation in the camps on self-esteem, mastery,

social competence, and QoL of young people with mental illness; and (ii) to

capture camp participants’ experiences of the program.

For the first part of the evaluation, a questionnaire battery was

administered at baseline (2 weeks prior to the camp), last day of the camp, and

at approximately 4-weeks post camp. For the second part of the evaluation, a

Camp Evaluation Questionnaire was administered on the last day of the camp.

In the questionnaire battery, demographic information (i.e., age, gender,

marital status, accommodation and living arrangements, and meaningful

activities) were obtained from participants.

Also included in the questionnaire battery were the Rosenberg Self-

Esteem Scale (RSES) (20), the Pearlin Mastery Scale (21), the Social

Connectedness Scale Revised (SCS-R) (22), the Social Anxiety and Distress Scale

(SADS) (23), and the World Health Organization Quality of Life Scale (WHOQoL-

Bref) (24).

The RSES (20) comprises 10 items which measure varying aspects of self-

esteem (see Appendix III). Each item is rated on a scale from 1 (strongly agree)

to 4 (strongly disagree). A total score then is derived (after taking into

consideration reversed scored items), with larger scores indicating higher self-

esteem. It has demonstrated usefulness in both adolescent and psychiatric

populations (25).


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The Pearlin Mastery Scale (21) comprises seven items which assesses “the

extent to which one regards one’s life-chances as being under one’s own control in

contrast to being fatalistically ruled” (see Appendix IV). The seven items are

scored on a 4-point scale ranging from 1 (strongly disagree) to 4 (strongly

agree), with a lower total score being indicative of having perceived control or

mastery over one’s own life.

The SCS-R (22) is a measure of how an individual perceives his/her

interpersonal closeness with the social world (see Appendix V). It comprises 20

items rated on a scale from 1 (strongly disagree) to 6 (strongly agree). The

higher the SCS-R total score, then the greater the sense of social connectedness.

Anxiety, anguish and fear in social situations will be assessed through the

SADS (see Appendix VI). This scale contains 20 items that focus on social

situations in which anxiety may occur. Respondents provide a true/false

response to statements such as “I am usually nervous with people unless I know

them well” or “Being introduced to people makes me tense and nervous”. A total

score is derived, again accounting for reversed scored items, with higher scores

indicating increased social anxiety.

The WHOQoL-Bref (24) was used as a global measure of QoL, as well as

providing indices of physical health, psychological health, social relationships

and environment (see Appendix VII). It comprises 26 items that are rated on a 5-

point scale. Scores are standardised to a scale with a range of 0-100 with higher

scores indicating better life satisfaction. The WHOQoL-Bref was only

administered at baseline and at 4-weeks post-camp follow-up.

The Camp Evaluation Questionnaire required evaluation of the camp

activities, the infrastructure (staffing, venue, food, duration of camp, cost of

camp), and the consumers’ experience of the program (things learnt through

participating, highlights and lowlights, suggestions for improvements) as well as

what advice participants would give to future campers (see Appendix IX).

The Camping Model

The camping model has been manualised (19). Philosophies

underpinning the camping program included partnerships, ‘Challenge by Choice’,

social connections, and physical health.

Strong partnerships were important for the successful planning and

delivery of the camping programs (19). The partnerships between mental health

and recreational sectors allowed individuals with mental health issues to

experience the camps, promoted social inclusion, and assisted with reducing

stigma through the training and education of volunteers and campsite staff (19).

‘Challenge by Choice’ respects the right of individuals to make decisions

and to voluntarily participate in activities. Overall the goal of ‘Challenge by

Choice’ is to impact on individual growth and development (26). It is based on

three principles: (i) individuals set their own goals; (ii) individuals choose how


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much of the activity that they are willing to experience; and (iii) participation in

activities is an informed decision (27).

Social inclusion was an important target of the camping program.

Individuals with mental illness are more likely to encounter stigma, social

isolation and exclusion (1). Through the group work offered in the camping

program, participants encountered team building and trust activities that

promoted their sense of connectedness (17, 19).

Individuals with mental illness have poorer physical health and are at

greater risk for cardiovascular disease (28). This is often due to lifestyle factors

such as sedentary behaviours, inadequate diets, and substance use (28). The

camping program engages individuals with all levels of fitness, shapes, and sizes

(19). By providing a safe and supportive environment, participants can

challenge their physical abilities.

A range of structured activities were included in the camps: giant swing,

low and high rope courses, giant swing, mountain biking, water activities, trust

and fellowship activities, etc. The activities slightly differed according the

facilities offered at each of the YMCA campsites and the time of year of the camp.

Activities were developed and sequenced with the intent of facilitating and

maximizing the positive identity of individuals; social competencies, and

providing support (see Table 1 for example content of a camp).

In most cases, the camps were offered and delivered to clients from a

single specific mental health service.


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Table 1

An example of structured and unstructured activities contained in a four-day camp.

Day Activities

One Introduction and orientation to the camp Footprints – everyone in the group gets to choose

colours that represent how they are feeling. Everyone paints their feet with their chosen colour and imprint on their canvas. This activity is delivered again at the end and the participants can compare their initial impressions to what they feel at the end of the camp

Open camp fire

Two Mountain bike Fuzzy bags –camp participants can provide positive

feedback to one another

Initiative games Low ropes course

Story of hope

Three Raft building Nutrition session and making lunch

Giant swing Fire of friendship

Four Physical activity games High ropes

Everyday Keeping a journal – for reflection of camp activities

My time - free recreational time

Procedures

Staff from the mental health services worked closely with YMCA Victoria

staff to aid with the recruitment of participants and to organise the camping

program. The mental health service staff identified individuals who satisfied the

inclusion criteria, as well as ascertained individuals’ interest in participating in a

camp. Staff from the mental health services also assisted participants with filling

out information referral forms. They also ensured that participants were fully

informed about the nature of the camping program.

There were a number of pre-camp sessions typically scheduled for 2

months prior to camp, 1 month prior to camp and two to one weeks prior the

camp. The aim of the pre-camp sessions was threefold: (i) for individuals to

meet other camp participants and to become familiarised with the leadership

team; (ii) the final camping program was discussed; and (iii) there was an initial

social and/or recreational activity such as bowling, horseriding, or a lunch. At

the pre-camp session, one-two weeks prior to the camp, a member from OYHRC

attended and provided a brief presentation on the aims of the evaluation project

and what was involved with participation. Participant Information and Consent


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Forms (PICF) and the questionnaire battery were distributed to camp

participants. Assistance with the completion of the forms was provided by

OYHRC and YMCA volunteers on an as needs basis. The questionnaires took an

average of 30 minutes to complete.

Camps were run at the YMCA managed campsites across Victoria. A

leadership team consisting of YMCA volunteers, mental health service staff and

campsite staff facilitated the camping program. A staff member from OYHRC

attended the last day of the camp and administered the questionnaire battery

and the Camp Evaluation Questionnaire, both of which took a total of 45 minutes

to complete on average.

At approximately four weeks post camp, a social and/or recreational

activity was scheduled; providing the camp participants the opportunity to

reunite, reminisce, and share experiences. A staff member from OYHRC attended

this session and administered the questionnaire battery, again taking

approximately 30 minutes to complete.

Data analysis

Data were analysed using the IBM®SPSS® Version 19. Descriptive

statistics (i.e., means, standard deviations, frequencies and counts) are reported

for the total cohort as well as separately for the participants in the “STEPS” and

“HORIZONS” camping programs. Although the differences between “STEPS” and

“HORIZONS” camps were minimal in terms of content and format, we have

presented data separately because of the different age ranges of the two cohorts.

One would anticipate that demographics, developmental issues, illness factors

may differ between these cohorts. To determine whether there were significant

changes in self-esteem, mastery, and social functioning, from baseline to four-

week follow-up, a series of mixed models repeated measures (MMRM) analysis

of variance were employed.

Cohen’s d was also reported to depict the size of the difference between

baseline and end of camp, and baseline and four-week follow-up. The standard

deviation at baseline was used in the computation. Cohen’s ‘rule of thumb’ was

used for interpreting the resultant standardised effect sizes (small effect d=0.20,

medium effect d=0.50, large effect d=0.80) (29).

The data from the Camp Evaluation Questionnaire were evaluated

descriptively.


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Results

Sample characteristics

A total of 120 individuals (males=77, females=43) participated in the camps,

and 90.0% (n=108) of those individuals partook in the camp evaluation. Reasons for

not consenting in the evaluation included: not interested in the evaluation;

psychiatric symptoms such as paranoia; literacy issues; or not attending the pre-

camp session.

Thirty-six young people and adults (males=25, females=11) with mental

illness participated in the five “STEPS” camps. Although the age range of 18-25 years

was targeted, the actual age range of participants on the “STEPS” camps ranged

from 17.7 to 33.6 years (M=23.8, SD=2.8). This discrepancy in ages was a result of

convenience sampling through the mental health services. The number of

participants in each of these five camps ranged from 5 to 12.

Seven of the twelve camps were run for 72 adults (males=47, females=25)

ranging in age from 18.3 to 72.0 years of age (M=41.2, SD=11.6). Again, although the

age range of 26+ years was targeted, participants’ ages depended on the clients

available at the particular mental health services. The number of participants in each

of the “HORIZONS” camps ranged from 8 to 14.

Table 2 details the demographic characteristics of the total cohort, as well as

separately for the participants of the “STEPS” and “HORIZONS” camps. The majority

of participants were male, never married, were residing in private residences, were

living alone, had commenced but not completed secondary education, and were on

a government pension.


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Table 2

Demographic characteristics of the total cohort, as well as separately for the

participants of the “STEPS” and “HORIZONS” camps

Total STEPS HORIZONS

(n=108) (n=36) (n=72)

Gender %Male % (n) 66.7 (72) 69.4 (25) 65.3 (47)

Age M (SD) 35.5 (12.6) 23.9 (3.2) 41.2 (11.6)

Marital status

Never married % (n) 72.1 (75) 100.0 (33) 59.2 (42)

Married/de facto % (n) 8.7 (9) 0.0 (0) 12.7 (9)

Other % (n) 19.2 (20) 0.0 (0) 28.2 (20)

Accommodation

Homeless % (n) 1.0 (1) 0.0 (0) 1.4 (1)

Private flat/house % (n) 60.4 (64) 30.6 (11) 75.7 (53)

Residential support/group home/boarding house

% (n) 32.1 (34) 69.4 (25) 12.9 (9)

Other % (n) 6.6 (7) 0.0 (0) 10.0 (7)

Live with?

Alone % (n) 40.0 (42) 22.9 (8) 48.6 (34)

Family/partner % (n) 33.3 (35) 22.9 (8) 38.6 (27)

Others % (n) 26.7 (28) 54.3 (19) 12.9 (9)

Vocational status

Home duties % (n) 6.7 (7) 5.7 (2) 7.1 (5)

Employed % (n) 10.5 (11) 14.3 (5) 8.6 (6)

Student % (n) 3.8 (4) 5.7 (2) 2.9 (2)

Pensioner % (n) 55.2 (58) 37.1 (13) 64.3 (45)

Unemployed % (n) 23.8 (25) 37.1 (13) 17.1 (12)

Highest level of education completed

Secondary not completed % (n) 52.0 (52) 61.8 (21) 47.0 (31)

Secondary completed 22.0 (22) 20.6 (7) 22.7 (15)

Diploma, trade certificate, Apprenticeship

% (n) 17.0 (17) 11.8 (4) 19.7 (13)

Tertiary % (n) 9.0 (9) 5.9 (2) 10.6 (7)

Participant Flow

For the overall cohort, the participation rates at the end of camp and four

weeks follow up were 85.2% (n=92) and 71.3% (n=77), respectively.


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Outcomes

Descriptive statistics for the psychological, social and QoL measures are

depicted in Table 3. For the overall cohort, there was significant change over

time in terms of mastery, F(2, 142.1)=5.32, p=.006; there was significant

improvement in mastery from baseline to end of camp, p=.001. This also

corresponded to improvements in self-esteem, F(2, 144.1)=6.39, p=.002, with

significant improvements seen from baseline to end of camp, p=.001. Social

connectedness changed significantly over time, F(2, 131.2)=8.33, p<.001, with

significant improvements observed between baseline and end of camp, p<.001.

No such changes were observed for social anxiety/distress and QoL measures.


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Table 3

Mean (and standard error) derived from mixed model repeated measures analysis of variance depicting changes over time in terms of

mastery-self-esteem, social connectedness, social anxiety, and quality of life, for the overall cohort as well as separately for the “STEPS” and

“HORIZONS” cohorts

Overall cohort STEPS HORIZONS

Baseline End of camp 4-weeks post camp

Baseline End of camp

4-weeks post camp

Baseline End of camp

4-weeks post camp

Rosenberg Self Esteem Scale a 27.3 (0.6) 29.0 (0.6) 28.0 (0.6) 27.1 (1.0) 28.3 (1.0) 27.6 (1.1) 27.4 (0.7) 29.3 (0.8) 28.2 (0.8)

Pearlin Mastery Scale b 16.1 (0.3) 15.1 (0.4) 15.6 (0.4) 16.3 (0.6) 15.6 (0.6) 16.1 (0.7) 16.0 (0.4) 14.9 (0.4) 15.4 (0.5)

Social Connectedness Scale c 74.6 (1.7) 79.1 (1.8) 76.8 (1.8) 73.8 (2.5) 78.1 (2.6) 75.3 (2.7) 74.9 (2.3) 79.6 (2.3) 77.4 (2.4)

Social Anxiety and Distress Scale d

14.4 (0.8) 13.4 (0.8) 13.7 (0.8) 14.4 (1.2) 12.1 (1.2) 12.9 (1.3) 14.3 (1.0) 14.0 (1.1) 14.1 (1.1)

WHOQoL-Bref e

Physical 59.3 (1.6) 59.4 (1.8) 59.6 (2.7) 62.7 (2.9) 59.1 (2.0) 57.8 (2.2)

Psychological 53.9 (2.1) 53.0 (2.2) 52.1 (3.4) 51.5 (3.8) 54.7 (2.6) 53.6 (2.8)

Social 56.9 (2.2) 55.2 (2.4) 54.9 (3.7) 52.4 (4.1) 57.9 (2.7) 56.9 (2.9)

Environmental 62.0 (1.7) 61.2 (1.8) 60.1 (3.0) 61.6 (3.2) 63.0 (2.0) 60.9 (2.2) a Scores range from 10-40, with higher self-esteem associated with higher scores bScores range from 4-28, with lower scores being associated with better self-esteem cScores range from 20-120, with higher scores indicating more social connectedness dScores range from 0-20, with higher scores indicating more social anxiety eScores range from 0-100, with higher scores indicating better QoL


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These analyses were also conducted separately for participants in the

“STEPS” and “HORIZONS” camps. For the participants in the “STEPS” camps

there were no overall difference between the three time points for all of the

measures; however, for social connectedness, F(2, 42.2)=2.55, p=.090, and social

anxiety, F(2, 33.0)=3.27, p=.051, test statistics were approaching significance.

Pairwise comparisons indicated that there were significant improvements seen

from baseline and end of camp for social connectedness, p =.035, and for social

anxiety, p=.015.

For the “HORIZONS” camps, there were significant improvements seen in

mastery, F(2, 90.0)=4.44, p=.015, self-esteem, F(2, 94.3)=5.06, p=.008, and social

connectedness, F(2, 88.27)=5.67, p=.005. Pairwise comparisons again

supported that view that the main differences were between baseline and end of

camp (mastery, p=.004; self-esteem, p=.008; and social connectedness, p=.001).

Examination of effect sizes, support the results of the MMRMs. Small to

moderate effects sizes were observed for baseline to end of camp for self-esteem,

mastery, social connectedness. The effect sizes for social anxiety were greater

for the “STEPS” cohort versus the “HORIZONS” cohort. Generally the effect sizes

were lower for baseline versus four-week follow-up.

Table 4

Cohen’s d values indicating effect sizes for changes between baseline and end of

camp, and baseline to four weeks follow-up, for the total cohort as well as for the

“STEPS” and “HORIZONS” cohorts

Overall cohort STEPS HORIZONS

Baseline - end of

camp

Baseline - 4

weeks post camp

Baseline - end of

camp

Baseline - 4

weeks post camp

Baseline - end of

camp

Baseline - 4

weeks post camp

Rosenberg Self Esteem Scale -0.27 -0.05 -0.16 0.05 -0.32 -0.08

Pearlin Mastery Scale 0.29 0.17 0.12 0.03 0.32 0.19

Social Connectedness Scale -0.25 -0.11 -0.20 0.04 -0.27 -0.17

Social Anxiety and Distress Scale 0.11 0.05 0.39 0.25 0.00 -0.01

WHOQoL-Bref

Physical 0.07 -0.17 0.11

Psychological 0.05 0.07 0.05

Social 0.13 0.20 0.09

Environmental 0.05 -0.07 0.14


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Qualitative

Quantitative and qualitative information was also derived from the Camp

Evaluation Questionnaire. All activities were rated favourably, with more

challenging activities such as low and high ropes courses and the giant swing

were rated highly. Camp leaders, venue, food and logistics of the camp were all

well received. Individuals reported on things that they had learnt about

themselves through participation in the camp program. General themes

included: (i) better mental and physical health; (ii) overall wellbeing; (iii)

improved self-esteem; (iv) confidence; (v) teamwork and trusting people; (vi)

communication and interactions with others.


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Discussion

This study highlights the collaborative work across the sectors of state

Government, mental health and community recreational services; a relationship

that is relatively novel in Australia. Data was collected on a large number of

individuals with various backgrounds, disorders, and life stage. Across the total

cohort, participation in the camping program resulted in significant

improvements in mastery, self-esteem, social connectedness, with these changes

observed between baseline (2 weeks prior to the camp) and the end of the camp.

The changes were not, however, sustained to a month post-camp.

Camping interventions can have an immediate impact on participants by

instilling a greater sense of wellbeing (15, 30). The ‘Challenge by Choice’

philosophy is integral to the camping intervention (26). Through the challenging

activities and extending participants’ boundaries, a greater sense of mastery and

self-esteem ensues. Several participants’ comments support the impact of the

camping on the sense of self, including: “Learned new skills-conquered fear of

heights” (“HORIZONS” camp participant); “I can overcome challenging/scary

obstacles” (“STEPS” camp participant), and “I can do everything as well as

everyone else, regardless of my size and mental illness” (“STEPS” camp

participant)”.

Participation in the group activities within the camping programs also

instilled a greater sense of social connectedness in participants. Team building

and trust activities were particularly useful for promoting this sense of

connectedness (17, 19). Social connectedness is characterised by “an attribute of

the self that reflects cognitions of enduring interpersonal closeness with the social

world in toto (31)”. One “HORIZONS” camp participant stated what he had learnt

from participating in the camp was that: “I can fit in with others” and “I am well

liked by others”. Another “HORIZONS” camp participant stated “I learned to enjoy

the company of others”.

With the group environment, there was not only the formation of

friendships and increased social connectedness, but an opportunity to further

develop social skills such as learning to cooperate and work with others, building

trust, and communication skills.

Social anxiety also reduced significantly from baseline to end of camp in

the “STEPS” camp participants. Psychosocial impairment is common in

adolescents and young adults who are first experiencing mental illness such as

depression (32). Indeed mental illness can impact on important developmental

tasks include socializing with friends, attending school, and/or pursuing

vocational goals (33). By providing a nurturing and supportive environment, and

supporting social skill development, social anxiety may be reduced. In a sense,

the camping environment fostered social inclusion. Promoting social inclusion is

important, particularly as individuals with mental illness are more likely to have


21

experienced stigma, social isolation and exclusion (1). Meaningful social

engagements and enhancing social networks can also positively influence self-

esteem, coping effectiveness, and promote psychological and physical wellbeing

(1, 34).

Adventure therapy programs can also have positive effects on physical

health (35). Although, not formally assessed, participants provided comments

that indicated a realisation of the benefits of physical activity: “I like physical

activity and things to do” and “fresh air, good exercise is good for me”. There were

also comments regarding the need to address physical health issues: “need to lose

weight”, “a lack of fitness”, “I should do more exercise”, and “I smoke too much”.

Thus, the camping program can increase participants’ awareness of lifestyle

factors such as sedentary behaviours and inadequate diets that can negatively

affect physical health (28). Examining ways to support these individuals in

making changes in health-related behaviours, may reduce the risk of later

cardiovascular or metabolic disorder.

Limitations

A conservative approach to the evaluation of the camping program was

adopted given the limited duration of the intervention (i.e., the camp is only 3-4-

days in length). We carefully selected a battery of standardised instruments that

would tap into self-esteem, mastery, social connectedness, rather than focusing

on issues such as diagnoses or symptomatology.

The length of the camping program may be too short to sustain outcomes;

a problem that has been previously reported (30). There is a need to consider

other ways in which to maintain the positive outcomes. One-way would be to

have regular ongoing activities or support groups that are offered post-camp.

Anecdotally, many of the participants reported that they enjoyed reuniting one

month post camp to share their experiences and participate in a new activity.

Linking participants into other YMCA activities and community-based services

could also be beneficial.

Variations to the format in which the adventure therapy is delivered

could also be considered. For example, at Orygen Youth Health, a yearly 10-

week outdoor adventure therapy program is run in conduction with Outdoors

Inc, a non-profit state wide recreational provider. Similar to the outcomes

reported here, participants in the 10-week program experience a greater sense

of self-esteem, accomplishment, and mastery (33) Participants also reported

significant changes in terms of self-improvement, being able to socialise with

others, social skills development, being able to manage symptoms, and to

manage time more effectively (33).

Other limitations associated with the study are small sample sizes and a

lack of control group. Small sample size was a specific problem for the “STEPS”

camps, with only 36 participants recruited. This reduced the chances or power


22

of detecting overall effects; however, pairwise comparisons supported

improvements in social connectedness and social anxiety from baseline to end of

camp. A control group would have strengthened the findings of current study,

but finding an appropriate control group was difficult. Logistical and resource

issues also restricted our ability to either run more “STEPS” camps and/or to

recruit a control group.

Implications

This project highlights the work of multiple sectors towards promoting

social inclusion of youth and adults with mental illness. It is evident from the

current findings that the positive personal and social mastery and connecting

experience of the camping process creates a window of opportunity for the

involved community mental health services. There is a need to capitalise upon

participants’ improved/heightened sense of self and social situation. Offering

‘follow-up’ programs for these individuals may sustain those positive changes

brought about by the camping experience over a longer period of time. One

participant offered this advice to others that may wish to participate in the

camping program: “Have a go and really challenge yourself! Why? Because you

will be amazed by how much you can really do!”


23

Appendices

Appendix I – Demographics Part 1 (Contact Details) for STEPS and HORIZONS

DEMOGRAPHICS Part 1 (Contact Details)

ID Number: _______

Name:

UR No: __ __ __ __ __ __ __

OCM: ___________________________________

1. Gender: M / F

2. DOB: __ __ / __ __ / __ __ __ __

Address: __________________________________________________

______________________________

3. Post Code: __ __ __ __

Contact Instructions

Phone 1 __________________

Phone 2 __________________


24

Appendix II – Demographics Part II

1. Today’s date __ __ / __ __ / __ __ __ __ 9 Are you doing any education, training, or employment at the moment (ie: in the last 2 weeks)

2. Type of Assessment

i) Employed No Yes

1) Initial 2) End of camp

3) 4-week follow-up If yes: Hours per week

3. Have you ever attended a HORIZONS camp before?

Describe:

No Yes

ii) Are you currently doing any secondary school subjects (eg: VCAL, Year 10, 11, 12)?

No Yes

4. What is your marital status (circle) If yes: Hours per week

1 Never married 2 Widowed 3 Divorced 4 Separated 5 Married (inc. de facto) 6 Not stated

Describe:

5.

What sort of accommodation do you usually live in?

0 None 1 Private flat/house 2 Resid. Support 3 Group Home 4 Boarding house 5 Hostel 6 Homeless shelter 7 Caravan 8 Other 9 Not known

iii) Are you doing any tertiary or vocational training (eg: TAFE certificates, apprenticeship)?

No Yes

If yes: Hours per week

6. Who do you live with? (NOTE: don’t write their

names, just their relationship to you eg: alone, parents, friends, housemates)

Describe:

iv) In the last 2 weeks, have you done any other regular activities eg: classes, groups, hobbies or interests that have structured times)? No Yes

7.

What is your employment status?

1 Home duties 2 Unemployed 3 Employed 4 Student 5 Pensioner 6 Child not at school 7 Not known

If yes: Hours per week

Describe:

8.

What is the highest educational level that you finished? (don’t include anything that you started but didn’t complete)

1 Primary school 2 Secondary Year ____ 3 Diploma, Trade Certificate, Apprenticeship 4 Tertiary completed 5 Not stated


25

Appendix III - Rosenberg Self-Esteem Scale Below is a list of statements dealing with your general feelings about yourself. If you STRONGLY AGREE circle SA. If you AGREE with a statement circle A. If you DISAGREE circle D. If you STRONGLY DISAGREE circle SD.

Strongly

agree Agree Disagree

Strongly disagree

1. On the whole, I am satisfied with myself. SA A D SD

2. At times I think I am no good at all. SA A D SD

3. I feel that I have a number of good qualities. SA A D SD

4. I am able to do things as well as most other people. SA A D SD

5. I feel I do not have much to be proud of. SA A D SD

6. I certainly feel useless at times. SA A D SD

7. I feel that I’m a person of worth, at least on equal plane with others. SA A D SD

8. I wish I could have more respect for myself. SA A D SD

9. All in all, I am inclined to feel that I am a failure. SA A D SD

10. I take a positive attitude toward myself. SA A D SD


26

Appendix IV - Pearlin Mastery Scale

How strongly do you agree or disagree with these statements about your self?

Strongly disagree

Disagree Agree Strongly

agree

1. There is really no way I can solve problems I have. SD D A SA

2. Sometimes I feel that I am being pushed around in life. SD D A SA

3. I have little control over the things that happen to me. SD D A SA

4. I can do just about everything I set my mind to do. SD D A SA

5. I often feel helpless in dealing with problems in life. SD D A SA

6. What happens to me in the future mostly depends on me. SD D A SA

7. There is little I can do to change many of the important things in my life. SD D A SA


27

Appendix V - Social Connectedness Scale – Revised

Directions: Following are a number of statements that reflect various ways in which we view ourselves. Rate the degree to which you agree or disagree with each statement using the following scale (1 = Strongly Disagree and 6 = Strongly Agree). There are no right or wrong answers. Do not spend too much time with any one statement and do not leave any unanswered.

Strongly disagree

Disagree Mildly

disagree Mildly agree

Agree Strongly

agree

1. I feel comfortable in the presence of strangers SD D MD MA A SA

2. I am in tune with the world SD D MD MA A SA

3. Even among my friends, there is no sense of brother/sisterhood SD D MD MA A SA

4. I fit in well in new situations SD D MD MA A SA

5. I feel close to people SD D MD MA A SA

6. I feel disconnected from the world around me SD D MD MA A SA

7. Even around people I know, I don't feel that I really belong SD D MD MA A SA

8. I see people as friendly and approachable SD D MD MA A SA

9. I feel like an outsider SD D MD MA A SA

10. I feel understood by the people I know SD D MD MA A SA

11. I feel distant from people SD D MD MA A SA

12. I am able to relate to my peers SD D MD MA A SA

13. I have little sense of togetherness with my peers SD D MD MA A SA

14. I find myself actively involved in people’s lives SD D MD MA A SA

15. I catch myself losing a sense of connectedness with society SD D MD MA A SA

16. I am able to connect with other people SD D MD MA A SA

17. I see myself as a loner SD D MD MA A SA

18. I don’t feel related to most people SD D MD MA A SA

19. My friends feel like family SD D MD MA A SA

20. I don't feel I participate with anyone or any group SD D MD MA A SA


28

Appendix VI - Social Avoidance and Distress Scale Does the statement apply to you? Please circle T for True and F for False.

True False

1. I feel relaxed even in unfamiliar social situations T F

2. I try to avoid situations which force me to be very sociable T F

3. It is easy for me to relax when I am with strangers T F

4. I have no particular desire to avoid people T F

5. I often find social occasions upsetting T F

6. I usually feel calm and comfortable at social occasions T F

7. I am usually at ease when talking to someone of the opposite sex T F

8. I try to avoid talking to people unless I know them well T F

9. If the chance comes to meet new people, I often take it. T F

10. I often feel nervous or tense in casual get-togethers in which both sexes are present T F

11. I am usually nervous with people unless I know them well T F

12. I usually feel relaxed when I am with a group of people T F

13. I often want to get away from people T F

14. I usually feel uncomfortable when I am in a group of people I don’t know T F

15. I usually feel relaxed when I meet someone for the first time T F

16. Being introduced to people makes me tense and nervous T F

17. Even though a room is full of strangers, I may enter it anyway T F

18. I would avoid walking up and joining a large group of people T F

19. When my superiors want to talk with me, I talk willingly T F

20. I often feel on edge when I am with a group of people T F

21. I tend to withdraw from people T F

22. I don’t mind talking to people at parties or social gatherings T F

23. I am seldom at ease in a large group of people T F

24. I often think up excuses in order to avoid social engagements T F

25. I sometimes take the responsibility for introducing people to each other T F

26 I try to avoid formal social occasions T F

27. I usually go to whatever social engagements I have T F

28. I find it easy to relax with other people T F


29

Appendix VII - World Health Organization Quality of Life Scale (WHOQoL-Bref)

Programme on Mental Health World Health Organization

Geneva

Quality of life

WHOQOL-BREF WHO/MSA/MNH/PSF/97.4

Instructions This assessment asks how you feel about your quality of life, health, and other areas of your life. Please answer all the questions. If you are unsure about which response to give to a question, please choose the one that appears most appropriate. This may often be your first response. Please keep in mind your standards, hopes, pleasures, and concerns. We ask that you think about your life in the last two weeks. Example:

Not at all

Slightly Moderately Very Completely

Do you get the kind of support from others that you need?

1 2 3 4

5

You would circle the number 4 if in the last two weeks you received a great deal of support from others. Not at

all Slightly Moderately Very Completely

Do you get the kind of support from others that you need?

1 2 3 4 5

You would circle number 1 if you did not get any of the support you needed from others

over the last two weeks.


30

Thank you for your help. Initial Question: Are you currently ill? Yes No If something is wrong with your health, what do you think it is? ____________________________________________________ illness / problem

Please read each question, assess your feelings for the last two weeks, then circle the number on the scale for each question that gives the best answer

for you. Very poor Poor Neither

poor nor good

Good Very good

1. How would you rate your

quality of life? 1 2 3 4 5

Very

dissatisfied Dissatisfied Neither

satisfied nor

dissatisfied

Satisfied Very satisfied

2. How satisfied are you

with your health? 1 2 3 4 5

The following questions ask about how much you have experienced certain things in the last two weeks.

Not at all A little A moderate amount

Very much

An extreme amount

3. To what extent do you feel that physical pain prevents you from doing what you need to do?

1 2 3 4 5

4. How much do you need any medical treatment to function in your daily life?

1 2 3 4 5

5. How much do you enjoy life?

1 2 3 4 5

6. To what extent do you feel your life to be meaningful?

1 2 3 4 5

Not at

all A little A

moderate amount

Very much

Extremely

7. How well are you able to concentrate

1 2 3 4 5

8. How safe do you feel in your daily life?

1 2 3 4 5


31

9. How healthy is your physical environment?

1 2 3 4 5

The following questions ask about how completely you experience or were able to do certain things in the last two weeks.

Not at

all A little Moderately Mostly Completely

10. Do you have enough

energy for every-day life? 1 2 3 4 5

11. Are you able to accept your bodily appearance?

1 2 3 4 5

12. Have you enough money to meet your needs?

1 2 3 4 5

13. How available to you is the information you need in your day-to-day life?

1 2 3 4 5

14. To what extent do you have the opportunity for leisure activities?

1 2 3 4 5

Very

poor Poor Neither

poor nor good

Good Very good

15.

How well are you able to get around?

1 2 3 4 5

The following questions ask you to say how good or satisfied you have felt about

various aspects of your life over the last two weeks.

Very

dissatisfied Dissatisfied Neither

satisfied nor

dissatisfied

Satisfied Very satisfied

16. How satisfied are you

with your sleep? 1 2 3 4 5

17.

How satisfied are you with your ability to perform your daily living activities?

1 2 3 4 5

18. How satisfied are you with your capacity for work?

1 2 3 4 5

19. How satisfied are you with yourself?

1 2 3 4 5

20. How satisfied are you with your personal relationships?

1 2 3 4 5

21. How satisfied are you with your sex life?

1 2 3 4 5

22. How satisfied are you with the support you get from your friends?

1 2 3 4 5


32

23. How satisfied are you with the conditions of your living place?

1 2 3 4 5

24. How satisfied are you with your access health services?

1 2 3 4 5

25. How satisfied are you with your transport?

1 2 3 4 5

The following question refers to how often you have

felt or experienced certain things in the last two weeks.

Never Seldom Quite

often Very often

Always

26. How often do you have

negative feelings such as blue mood, despair, anxiety, depression?

1 2 3 4 5


33

Appendix VIII – Final Questions

FINAL QUESTIONS

1. How long did it take you to complete this assessment? ____________

2. Did someone help you with the assessment? Yes / No

2a. If yes, who? (circle correct response)

i. ORYGEN staff

ii. YMCA staff or other worker

iii. Other camp participant

iv. Friend / family member

v. Other _________________________________

2b. If yes, what sort of help? (circle as many as apply)

i. Occasional help / clarification

ii. Reading less than half of the questions

iii. Reading most/all of the questions

iv. Doing less than half of the writing

v. Doing most/all of the writing

vi. Other __________________________________

3. Do you have any comments about the assessment?

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

THANKYOU VERY MUCH FOR YOUR HELP


34

Appendix IX – Camp Evaluation Questionnaire

YMCA ‘HORIZONS’ CAMP Main Connection – Anglesea

Evaluation

Thank-you for attending the 4-day HORIZONS camp run by the YMCA and supported by Sports and Recreation Victoria. In order to get an idea of whether the camp was helpful for you and to help plan for future programs, please complete the following questions. This information will be collated by staff at ORYGEN Research Centre and a report will be generated for quality assurance purposes. No identifying information will be provided in this report. 1. Please rate each aspect of the program using a scale from 1 to 10. A score of 1 refers to ‘extremely poor’ and a score of 10 refers to ‘extremely good/excellent’. If you have any comments, please place them in the space provided.

Day of Camp

The Activities Rating Comments

One Horizons Welcome

Beach – Play Time, Walk

Fuzzy Bags & Journal Making

Two Archery

Bike Ride or Walk

Rocking Good Time

Low Ropes

Survivor Challenge Water Based (Canoe)

Horizons Time


35

Day of Camp

The Activities Rating Comments

Trivia Night

Three Jenga

Giant Swing Pod

Surfing

Group Reflection at Beach

Horizons Time

Night Walk

Fire Of Friendship

Four Favourite Activity (Archery/Low ropes/Giant Swing/Walk/Ride)

Fuzzies, Horizons Awards & Goodbye

Any other comments:


36

The program Rating Comments

HORIZONS Leaders

Venue

Food

Duration of camp

Any other comments: 2. Name 3 things you learnt about yourself through participating in the camp.

(e.g., skills, mental health, general health and wellbeing, etc.)

1.______________________________________________ 2.______________________________________________ 3.______________________________________________

3. What was the highlight of the camp for you? 4. What was the least enjoyable part of the camp for you? 5. What activity did you find the most challenging?


37

6. What would like to see added to the camp’s program? 7. What would like to see less of in the camp’s program? 8. What changes would you suggest in order to improve HORIZONS? 9. What advice would you give to future participants (and why)? 10. Any other comments?

Thank-you for your participation!


38

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