492351

2013
APY21410.1177/1039856213492351Australasian PsychiatryCotton and Butselaar

AP
Psychosocial interventions

Australasian Psychiatry

Outdoor adventure camps for 21(4) 352­–358

© The Royal Australian and
New Zealand College of Psychiatrists 2013

people with mental illness Reprints and permissions:

sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1039856213492351
apy.sagepub.com

Sue Cotton  Principal Research Fellow, Orygen Youth Health and Centre for Youth Mental Health, University of Melbourne,
Melbourne, VIC, Australia
Felicity Butselaar  Research Assistant, Orygen Youth Health and Centre for Youth Mental Health, University of Melbourne,
Melbourne, VIC, Australia

Abstract
Objective: The aim of the study was to evaluate a novel outdoor adventure camping program for individuals with
mental illness.
Method: The program was developed by YMCA Victoria in partnership with Sport and Recreation Victoria, and
mental health service agencies. Orygen Youth Health Research Centre conducted the program evaluation. One hun-
dred and eight individuals from mental health services across Victoria participated in 12 camps. Five camps targeted
young people between the ages of 18 and 25 years. Seven camps were run for adults 26 years and older. Participants
were assessed at baseline, end of camp, and four weeks following the camp in terms of self-esteem, mastery, and
social connectedness. Quality of life was assessed at baseline and four weeks post-camp.
Results: 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 four-week follow-up.
Conclusions: We have demonstrated that utilizing the expertise of mental health services and a community recrea-
tion provider can benefit individuals experiencing mental illness. More research is required with respect to how to
sustain these benefits over the longer term.

Keywords:  chronic mental illness, early mental illness, group therapies, outdoor adventure, psychosocial recovery

P
sychopharmacology advances improve symptom
outcomes for individuals with mental illness; how-
ever, functioning often remains impaired. Social
isolation, common in individuals with mental illness, is
also associated with poorer mental and physical health
in the longer term.1
Alternative treatment models, such as adventure ther-
apy, encourage social and practical engagement to
increase functionality, and provide promise as an adjunct
to traditional therapy.2 Adventure therapy has been used
for individuals with a range of mental health issues
including delinquency,3 depression,4 and psychosis.5
Adventure therapy involves intentional and facilitated use
of tools to guide personal change towards desired thera-
peutic goals.6 Camping programs are one type of adven-
ture therapy, with the philosophy of ‘learning by doing’.7
Adventure therapies significantly increase participants’
self-esteem, self-confidence, and a shift towards an inter-
nal locus of control.8 They especially benefit individuals
who are withdrawn and have difficulty maintaining
social connections. Improvements in anxiety and depres-
sion have also been reported.9 Such factors have positive
influences on rehabilitation outcomes.10
Methodological issues associated with the evaluation of
adventure therapy programs include variance in camp
programs, small sample sizes, lack of control groups, and
absence of standardized assessment tools. Research eval-
uating the effectiveness of camping programs for indi-
viduals with mental illness is sparse.
Following a 2002 review, Sport and Recreation Victoria
(SRV), a State Government department, highlighted the
inequities experienced by people with mental illness to
community run camping and outdoor recreation oppor-
tunities. Working with YMCA Victoria, SRV initiated and
Correspondence:
Associate Professor Sue Cotton, Orygen Youth Health Research
Centre, University of Melbourne, Locked Bag 10 (35 Poplar
Road), Parkville, VIC 3052, Australia.
Email: smcotton@unimelb.edu.au

352
Cotton and Butselaar
funded the development of the Mental Health Access
and Participation and Industry Mentoring Project, or
‘Journey to Strength’.11 YMCA Victoria, government rep-
resentatives, and mental health and community agencies
were involved in the planning and development of a
four-day camping program with the aim of enabling par-
ticipants to develop a positive identity, improve social
competencies and broaden supportive relationships.
Here we present the results of the program evaluation. It
was hypothesized that over the course of the camp and
at the four-week follow-up, participation in the program
would result in: (a) higher self-esteem and mastery; (b)
improved social and occupational functioning; (c)
reduced social withdrawal/isolation through encourag-
ing peer support, self-esteem and confidence; and (d)
enhanced quality of life (QoL).
Methods
Participants
Clients from nine mental health services across Victoria
participated in 12 camps. Five camps were for individu-
als between the ages of 18 and 25 years; the ‘STEPS’
camps. Seven camps were run for adults with mental ill-
ness aged 26 years and older; the ‘HORIZONS’ camps.
Whilst the ‘STEPS’ and ‘HORIZONS’ camps were target-
ing different age groups, the planning and implementa-
tion process was very similar for each.11
Inclusion criteria included a stable mental state, and no
risk of harm to self or to others. Informed consent was
gathered from all participants, and the study was
approved by various institutional ethics committees.
Measures
Orygen Youth Health Research Centre (OYHRC) con-
ducted the evaluation of the camping program. The
evaluation had two goals: (1) to determine the impact of
camp participation on self-esteem, mastery, social com-
petence, and QoL in people with mental illness; and (2)
to capture participants’ experiences of the program.
A questionnaire battery was administered at baseline (two
weeks prior to camp), last day of camp, and approximately
four weeks post-camp. A Camp Evaluation Questionnaire
was administered on the last day of camp. QoL was
assessed at baseline and four weeks post-camp. In the
questionnaire battery, demographic information (i.e. age,
gender, accommodation, and vocation) was obtained.
The test battery included the Rosenberg Self-Esteem
Scale (RSES), the Pearlin Mastery Scale (PMS),12 the Social
Connectedness Scale Revised (SCS-R),13 the Social
Anxiety and Distress Scale (SADS),14 and the World
Health Organization QoL Scale (WHOQoL-Bref).
The Camp Evaluation Questionnaire required evalua-
tion of the camp activities, infrastructure (e.g. staffing),
and consumers’ experience of the program (things
learnt through participating, highlights and lowlights,
improvement suggestions) as well as any advice for
future campers.
The camping model
The camping model has been manualized.11 Philosophies
underpinning the program included partnerships, ‘Challenge
by Choice’, social connections, and physical health.
Strong partnerships were important for successful
planning and delivery of the programs.11 Partnerships
between mental health and recreational sectors
allowed individuals to experience the camps, pro-
moted social inclusion, and assisted with reducing
stigma through training and educating volunteers and
campsite staff.
‘Challenge by Choice’ involves three principles: (1) indi-
viduals set their own goals; (2) individuals choose how
much of the activity that they are willing to experience;
and (3) participation is an informed decision.11
Through group work, participants encountered team
building and trust activities that promoted their sense of
inclusion.11
Individuals with mental illness have poorer physical
health and are at greater risk of cardiovascular disease due
to lifestyle factors such as poor diets and substance use.15
The camping program engages all levels of fitness, shapes,
and sizes.11 By providing a safe and supportive environ-
ment, participants can challenge their physical abilities.
A range of structured activities were offered and there
was some variation in what was offered according to the
facilities at the YMCA campsites and the time of year.
Activities were developed and sequenced with the intent
of promoting positive identity, social competencies, and
providing support (see Table 1).
In most cases, the camps were offered and delivered for
a single mental health service, varying with each camp.
Procedures
Staff from mental health services worked closely with
YMCA Victoria to aid with participant recruitment and
the organization of camping programs.
Pre-camp sessions were scheduled for two months, one
month and two weeks prior to the camp. The aim of
these sessions was threefold: (1) for individuals to meet
other camp participants and become familiarized with
their leadership team; (2) for familiarization with the
camping program; and (3) for an initial social recrea-
tional activity (e.g. horse-riding). The session two weeks
prior to camp was attended by an OYHRC member and
a brief presentation on the evaluation project was pro-
vided. Written informed consent was obtained and the
questionnaire battery was administered. Assistance with
form completion was provided on an as-needs basis,
353
 Australasian Psychiatry 21(4)

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
Every day Keeping a journal – for reflection of camp activities
  My time – free recreational time

with questionnaires taking an average of 30 minutes to
complete.
Camps were run at YMCA-managed campsites. A lead-
ership team consisting of YMCA volunteers, mental
health service staff, and campsite staff facilitated the
camping program. Staff from OYHRC attended the last
day of the camp and administered the questionnaires,
which took 45 minutes to complete on average.
of thumb’ was used for interpreting the resultant
standardized effect sizes (e.g. medium effect d=0.50).
Data from the Camp Evaluation Questionnaire were
evaluated descriptively.
Results
Sample characteristics

At approximately four weeks post-camp, another social
recreational activity was scheduled; providing camp
participants the opportunity to reunite, reminisce, and
share experiences. A staff member from OYHRC
attended this session and administered the question-
naire battery, taking approximately 30 minutes to
complete.
Data analysis
Descriptive statistics are reported for the total cohort
as well as separately for the ‘STEPS’ and ‘HORIZONS’
programs. Although the differences between ‘STEPS’
and ‘HORIZONS’ camps were minimal in terms of con-
tent and format, data is presented separately because
of the different age ranges of the cohorts. To determine
any 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 reported to depict the size of the difference
between the different time points; baseline standard
deviation was used in the computation. Cohen’s ‘rule
120 individuals (males, n=77) participated in the camps,
and 90.0% (n=108) of those individuals partook in the
evaluation. Reasons for non-consent included: not inter-
ested in the evaluation; psychiatric symptoms such as para-
noia; poor literacy; or not attending pre-camp sessions.
Thirty-six individuals (males n=25) participated in the
‘STEPS’ camps. Although the age range of 18–25 years
was targeted, the actual age range of participants ranged
from 17.7 to 33.6 years (M=23.8, SD=2.8). This discrep-
ancy in ages was a result of convenience sampling
through mental health services. Participation numbers
in the camps ranged from five to 12.
Seven ‘HORIZONS’ camps were run for 72 adults (males
n=47) ranging in age from 18.3 to 72.0 years (M=41.2,
SD=11.6). Again, although the age range of 26+ years was
targeted, participants’ ages depended on the clients at
the particular mental health services. Participation num-
bers in the ‘HORIZONS’ camps ranged from eight to 14.
Most participants were male, never married, residing in
private residences, living alone, had commenced but not
completed secondary education, and were on a govern-
ment pension (see Table 2).

354
Cotton and Butselaar

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)
Note: percentages may be calculated on the basis of different denominators due to the presence of missing data.

Participant flow improvements observed between baseline and end of

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.
Outcomes
For the overall cohort, there was significant change
over time in terms of mastery, F(2,142.1)=5.32, p=.006;
with improvement in mastery from baseline to end of
camp, p=.001 (see Table 3). Similarly, there were
improvements in self-esteem, F(2,144.1)=6.39, p=.002,
with significant increases seen from baseline to end of
camp, p=.001. Social connectedness also changed sig-
nificantly over time, F(2,131.2)=8.33, p<.001, with
camp, p<.001.
For ‘STEPS’ participants, there was no overall difference
between the three time points for all of the measures;
however, social connectedness, F(2,42.2)=2.55, p=.090,
and social anxiety, F(2,33.0)=3.27, p=.051, approached
significance. Pairwise comparisons indicated that there
were significant improvements seen from baseline to
end of camp for social connectedness, p=.035, and for
social anxiety, p=.015.
For ‘HORIZONS’ participants, significant improvements
were 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
found that the main differences were between baseline

355
 Australasian Psychiatry 21(4)

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 4 weeks Baseline End of 4 weeks Baseline End of 4 weeks

camp post-camp camp post-camp camp post-camp
Rosenberg Self 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)
Esteem Scalea
Pearlin Mastery 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)
Scaleb
Social 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)
Connectedness
Scalec
Social Anxiety 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)
and Distress
Scaled
WHOQoL-Brefe
 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)
aScores 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 quality of life.

WHOQoL-Bref: World Health Organization Quality of Life Scale

and end of camp (mastery, p=.004; self-esteem, p=.008; Discussion

and social connectedness, p=.001).
Examination of effect sizes support the results of the
MMRMs. Small to moderate effect sizes were observed
for baseline to end of camp for self-esteem, mastery, and
social connectedness. The effect size for social anxiety
was greater for the ‘STEPS’ than ‘HORIZONS’ cohort, and
effect sizes were lower for baseline versus four weeks
post-camp (see Table 4).
Qualitative
All activities were rated favourably, with more challeng-
ing activities rated highest. Camp leaders, venue, food,
and logistics of camp were well received. Individuals
reported on things that they had learnt about themselves
through participation in the program. Themes included:
(a) better mental and physical health; (b) overall well-
being; (c) improved self-esteem; (d) confidence; (e) team-
work and trust; (f) communication and interactions with
others.
This study highlights collaborative work across govern-
ment, mental health and community recreational sec-
tors; a relationship that is novel in Australia. Data was
collected on a large number of individuals with various
backgrounds, disorders, and life stage. Across the cohort,
participation resulted in significant improvements in
mastery, self-esteem, and social connectedness, with
these changes observed between baseline and the end of
the camp. The changes were not sustained to a month
post-camp.
Camping interventions have an immediate impact on
participants by instilling a greater sense of wellbeing.16
The ‘Challenge by Choice’ philosophy is integral to the
camping experience with challenging activities extend-
ing participants’ boundaries.17 A greater sense of mastery
and self-esteem ensues; participants commented:
‘Learned new skills – conquered fear of heights’ (‘HORIZONS’);
and ‘I can do everything as well as everyone else, regardless
of my size and mental illness’ (‘STEPS’).

356
Cotton and Butselaar

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 – Baseline – Baseline – Baseline – Baseline – Baseline –

end of camp 4 weeks end of camp 4 weeks end of camp 4 weeks
post-camp post-camp post-camp
Rosenberg Self –0.27 –0.05 –0.16 0.05 –0.32 –0.08
Esteem Scale
Pearlin Mastery 0.29 0.17 0.12 0.03 0.32 0.19
Scale
Social –0.25 –0.11 –0.20 0.04 –0.27 –0.17
Connectedness
Scale
Social Anxiety 0.11 0.05 0.39 0.25 0.00 –0.01
and Distress
Scale
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
WHOQoL-Bref: World Health Organization Quality of Life Scale

Participation in group activities instils social connected- Limitations

ness, with team building and trust activities particularly
useful.8 One ‘HORIZONS’ participant stated that: ‘I can
fit in’ and another ‘HORIZONS’ participant stated ‘I
learned to enjoy the company of others’.
Within the groups, there was not only the formation of
friendships and increased connectedness, but an oppor-
tunity to further develop social skills such as cooperat-
ing with others, building trust, and communication.
Social anxiety reduced significantly from baseline to end
of ‘STEPS’ camps. Mental illness impacts on develop-
mental tasks including socializing with friends, attend-
ing school, and/or pursuing vocational goals.18 By
providing a nurturing and supportive environment, and
supporting social skill development, social anxiety may
be reduced, fostering social inclusion. Meaningful social
engagements and enhancing social networks can also
positively influence self-esteem, coping effectiveness,
and promote psychological and physical wellbeing.1
Adventure therapy has positive effects on physical
health.19 Although not formally assessed, participants
commented: ‘I like physical activity’ and ‘fresh air is good
for me’. The need to address physical health issues was
also raised: ‘need to lose weight’, ‘I should do more exercise’,
and ‘I smoke too much’. Examining ways to support these
individuals in making changes in health-related behav-
iours may reduce the risk of later medical complication.
A conservative approach to evaluation of the program
was adopted given the limited duration of intervention.
The length of the program may be too short to sustain
outcomes; a problem previously reported.16 Alternative
ways to maintain positive outcomes are needed. One
option would be to have regular ongoing activities or
support groups offered post-camp. Anecdotally, many
participants reported enjoying reuniting one month
post-camp to share their experiences and participate in
further activity. Linking participants into other YMCA
and community-based services could also be beneficial.
Variations to the format in which adventure therapy is
delivered could also be considered. For example, at
Orygen Youth Health Clinical Program (OYHCP), an
annual 10-week outdoor adventure therapy program is
run in conduction with Outdoors Inc, a non-profit
state-wide recreational provider. Similar to the out-
comes reported here, participants in the 10-week pro-
gram experience a greater sense of self-esteem,
accomplishment, and mastery, with significant changes
in terms of self-improvement, social skills development,
being able to manage symptoms, and effective time
management.18
Other limitations with the study are small sample sizes
and lack of control group. Small sample size was a specific
problem for the ‘STEPS’ camps, with only 36 participants.

357

This reduced the chances of detecting overall effects;
however, pairwise comparisons supported improvements
from baseline to end of camp. A control group would
have strengthened the findings of the current study, but
finding an appropriate group was difficult. Logistical and
resource issues restricted our ability to run more camps
and to recruit a control group.
Conclusions
This project highlights the work of multiple sectors
towards promoting social inclusion of individuals with
mental illness. The positive personal, social mastery
and connecting experience of participation creates a
window of opportunity for community mental health
services to capitalize upon participants’ improved sense
of self and social situation. Offering ‘follow-up’ pro-
grams for these individuals may sustain these positive
changes brought about by the experience over a longer
period of time. One participant offered this advice to
other prospective campers: ‘Have a go and really chal-
lenge yourself! Why? Because you will be amazed by how
much you can really do!’
Acknowledgements
This is an evaluation of the impact of the YMCA Victoria’s Journey to Strength camping pro-
gram for individuals with mental illness. The evaluation was conducted in conjunction with
YMCA Victoria, Sport and Recreation Victoria, and local mental health service agencies.
There are several people and organizations that must be thanked for their support for this
evaluation project. First, 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. Second, thanks goes to Liz Leorke, Project Director, who developed
the model and approached the entire project with much passion, creativity and open mind-
edness. Third, we acknowledge the contributions from the range of people and organiza-
tions 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 of 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.
Fourth, 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, and Orygen Youth Health Clinical Program.
Funding
The camping program and evaluation was financially supported by the Department of Planning
and Community Development (Sport and Recreation Victoria division), State Government of
Victoria.
358
Australasian Psychiatry 21(4)
Disclosure
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of the paper.
References
1. VicHealth. Social inclusion as a determinant of mental health and wellbeing. In: Mental
Health and Wellbeing Unit, (ed) Melbourne: VicHealth, 2005. Available at: http://www.
vichealth.vic.gov.au/Publications/Social-connection/Social-Inclusion-as-a-determinant-
of-mental-health-and-wellbeing.aspx (accessed 27 June 2013).
2. Cason D and Gillis HL. A meta-analysis of outdoor adventure programming with adoles-
cents. Journal of Experiential Education 1994; 17: 40–47.
3. Wilson SJ and Lipsey MW. Wilderness challenge programs for delinquent youth: a meta
analysis of outcome evaluations. Eval Program Plann 2000; 23: 1–12W.
4. Norton CL. Into the wilderness—a case study: the psychodynamics of adolescent
depression and the need for a holistic intervention. Clin Soc Work J 2010; 38:
226–235.
5. Pawlowski M. Wilderness therapy for psychiatric disorder. Ment Health Aust 1993; 5:
8–14.
6. Alvarez AG and Stauffer GA. Musings on adventure therapy. J Exp Educ 2001; 24: 85–91.
7. Brown KJ. Therapeutic camping programs. In: Steele RG and Roberts MC (eds) Handbook
of mental health services for children, adolescents, and families. New York: Kluewer
Academic/Plenum Publishers, 2005, pp. 305–315.
8. Ewert AW, McCormick BP and Voight AE. Outdoor experiential therapies: implications
for TR practice. Therapeutic Recreation Journal 2001; 35: 107–122.
9. Kelley MP, Coursey RD and Selby PM. Theraeputic adventures outdoors: a demonstration
of benefits for people with mental illness. Psychiatr Rehabil J 1997; 20: 61–73.
10. Norman EL and Norman VL. Relationship of patient’s health locus of control beliefs to
progress in rehabilitation. J Rehabil 1991; 57: 27–30.
11. YMCA Victoria. Journey to strength. Melbourne: YMCA Victoria, 2011.
12. Pearlin LI, Menaghan EG, Lieberman MA and Mullan JT. The stress process. J Health
Soc Behav 1981; 22: 337–356.
13. Lee RM, Draper M and Lee S. Social connectedness, dysfucntional interpersonal behav-
iours, and psychological distress: testing a mediator model. J Counsel Psychol 2001; 48:
310–318.
14. Watson D and Friend R. Measurement of social-evaluative anxiety. J Consult Clin Psy-
chol 1969; 33: 448–457.
15. Davidson S, Judd F, Jolley D, Hocking B, Thompson S and Hyland B. Cardiovascular risk
factors for people with mental illness. Aust New Zeal J Psychiatr 2001; 35: 196–202.
16. Herbet JT. Therapeutic effects of participating in an adventure therapy program. Rehabil
Counsel Bull 1998; 41: 201–216.
17. Haras K, Bunting CJ and Witt PA. Linking outcomes with ropes course program design
and delivery. J Park Recreat Admi 2005; 23: 36–63.
18. Schell L, Cotton S and Luxmoore M. Outdoor adventure for young people with a mental
illness. Early Intervention in Psychiatry in press; 2012; 6: 407–414.
19. Pryor A, Carpenter C and Townsend M. Outdoor education and bush adventure therapy: a
socio-ecological approach to health and wellbeing. Australian Journal of Outdoor Educa-
tion 2005; 9: 3–13.