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The Real Trail Angels

Sarah Cazares helps finish a trucker’s hitch to tension out one of her student’s A-frames. The cordage twangs as she draws the line tighter, not dissimilar from tuning a guitar. “Do you have a stake?” she asks. The student produces one from a downed branch nearby, “Found one!” She hands it to Sarah, who holds it behind her knee, between her upper and lower leg, and snaps a section off with one hand while maintaining tension on the line with the other. She sinks the steak into the sandy, riverbank soil, stands up, and brushes off her hands. By the end of the week, Sarah will have weened the students off her assistance in camp chores.

Cazares is a field therapist for Blackwater Outdoor Experiences. She is leading a trip of six adolescent students on a 22-day expedition canoeing, backpacking, and rock climbing through the Appalachian region. Today is day three, and she’s already proven herself unwaveringly patient and nurturing. She’s also tough as nails.

Often an overlooked approach to treatment, expedition-based wilderness therapy is gaining some momentum. Nature walks have been a prescribed as a de-escalation technique for years, but not until recently has expedition-based wilderness therapy gained wider recognition as a legitimate treatment option, especially for adolescents and young adults. To continue to grow this trend, the Outdoor Behavioral Healthcare (OBH) council encourages wilderness therapy programs to facilitate outcomes based research; Cazares is responsible for collecting voluntary saliva samples as part of a larger research study on the effects of wilderness exposure and stress. The samples will be delivered to Dr. Catherine Franssen of Longwood University whose research team will measure the cortisol levels in an effort to draw more detailed conclusions on the effectiveness of wilderness therapy in reducing stress and assess its viability as a treatment option for those suffering from mental health and substance abuse disorders. The results thus far are promising.

Franssen says that in the 2 years of research she’s been conducting with Blackwater Outdoor Experiences, she’s seen significant changes in stress hormones over the course of the three-week experience. “Stress hormones, like cortisol, help us to identify how the body is reacting to and recovering from a variety of challenges in the environment. Obviously, these hormones differ some in students with diagnosed anxiety disorders versus those who aren’t, but not as much as you might expect.” Franssen is finding that the three-week trip is changing overall stress responses. “Students start out on Day 1 with very high cortisol levels,” she says “but then after a week and a half, their levels drop significantly. They start to elevate at the end of the trip, as they are reentering the ‘real world’ but are still much lower than the start of trip.” This sort of physiological change, Franssen explains, demonstrates that the trip is changing both mind and body, and might help us to understand the underlying mechanisms of how wilderness therapy is exerting its effects. Franssen is further exploring how students with different primary diagnoses respond to wilderness therapy, and hopes to be able to identify populations which may benefit most from this method.

Recent revenue code amendments appear to support this movement. The National Uniform Billing Committee (NUBC) established revenue code 1006, effective as of July 1, 2017, that enables major providers to bill wilderness therapy programs within their plans, though it’s up to providers to actually cover the service.

Still, accessibility is limited to wilderness-based therapy as it does not meet the definitions of clinical-residential treatment centers put forth by many insurance providers, including Medicaid, and is predominately a self-pay treatment option perceived as a luxury.  As Blue Choice states in policy MED.00122, “To date, wilderness programs have not been sufficiently studied to show effectiveness, safety, relevance, and/or reliability in peer-reviewed medical literature.” Further, that, “Wilderness programs have not shown significant medical benefits for children, adolescents or adults with medical, including behavioral health, conditions” (accessed July 27, 2017).

Continued research on the effectiveness of expedition-based OBH programs like Blackwater Outdoor Experiences and the efforts made by OBH council, with their strict accreditation standards, will further validate calls for recognition by major insurance providers as more people begin to move to experiential treatment as a primary care option. Until then, wilderness therapy will continue to be categorized with complementary treatment options such as hypnosis and acupuncture, as is the case in AmeriHealth’s policy 12.00.03e (accessed July 27, 2017).

For Cazares, the days are mentally grueling. Rustling beneath her tarp, careful not to wake the students, she begins to crash camp as early as 5:30. Deciding how to spend her few moments of personal time in the early mornings is an ongoing battle between extra sleep and transcribing her notes, which grow longer by the hour. She’s been forced into typing her notes this morning because of her proximity to a wireless service area—she’ll scramble up to higher ground when’s she’s finished to upload her observations so the clinical staff back at HQ can stay up-to-date.

At 7:00, Sarah makes her rounds and gently wakes the students. “Good morning! How’d you sleep?” They grumble inaudibly. Mornings in at the camp sites are slow. The focus is on the therapy, not so much the activities. “It’s time to get up—It’s going to be a beautiful day!” A packed bag is a ticket to breakfast, and while this helps with motivation, it’s more the principle of the thing. By 9:00, everyone has been fed and watered, and Sarah is priming the morning’s psychoeducational lesson. Today, she’s discussing the “Levels of Communication Onion.” She takes a large Rubbermaid lid from the kitchen bin and slides a fresh white garbage bag over it to make a field-whiteboard. She begins to draw a rainbow-esque arc structure and labels each descending level: clichés & rituals, facts, opinions and beliefs, feelings, the core.

Cazares breaks the students into pairs to discuss potential correlations between their personal relationships and the levels of communication. Encouraging them to delve deeper, Cazares facilitates a few moments of conversation with each group before moving on. One student was having a particularly hard time grasping the concept of the levels being unique to the depth and intimacy of the relationship.

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