The Importance of Gender-Matching between Wilderness Therapy Guides and Clients in Predicting Positive Client Outcomes

The Importance of Gender-Matching between Wilderness Therapy Guides and Clients in Predicting Positive Client Outcomes

            Wilderness therapy guides play a unique and significant role in the experiences that clients have in the field. Many outdoor behavioral healthcare programs have a rotating staff structure in which clients are exposed to teams of field guides for one week at a time and are likely to work with several different individual guides and guide-team combinations over the course of treatment (Russell, Hendee, & Phillips-Miller, 2000). Field guides are typically with clients 24 hours per day, seven days per week, facilitating logistics and therapeutic processes on both individual and group levels (Bunce, 1998). As such, guides play an important role in shaping the clients’ experiences. Therapeutic alliance between clients and field guides is understood to be one of the key agents of change for wilderness therapy clients (Russell & Phillips-Miller, 2002), but little is known about the factors that influence therapeutic alliance, suggesting the need for further research on the specific nature of field guide-client relationships.

To date, very little research has addressed the experiences of wilderness therapy guides (Bunce, 1998; Marchand, Russell, & Cross, 2009; Marchand, 2010), and there have been no studies that focus on aspects of the relationships between guides and clients. Wilderness therapy guides have the potential to fulfill a variety of powerful roles in the clients’ experience. Clients in residential settings may look to staff as role models, as therapists, or as parent figures (Moses, 2000), and effective staff members can do a lot to address and reshape clients’ unhealthy patterns of thought and behavior (Russell & Phillips-Miller, 2002). Because therapeutic alliance may be the primary means through which wilderness therapy guides can effect change in their clients, one way for programs to improve client outcomes could be to match clients and guides who are most likely to build strong relationships. Gender-matching could be one of the factors that contributes to the formation of therapeutic alliance, as has been shown to be the case in studies that address relationships between clients and therapists, outdoor education instructors, and college role models (Bhati, 2014; Lockwood, 2006; Neill, 1997; Wintersteen, Mensinger, & Diamond, 2005). In the setting of wilderness therapy, gender may also be a factor in predicting the strength of relationships between clients and field guides.

Therapeutic Alliance

The importance of therapeutic alliance to client growth and reduction of symptoms is widely recognized (Bickman et al., 2004; Klein et al., 2003; Manso, Rauktis, & Boyd, 2008; Marcus, Kashy, Wintersteen, & Diamond, 2011; Vosciano et al., 2004). Marcus et al. (2011) explored the complexities of therapeutic alliance in the context of adolescent substance abuse treatment, where, similar to wilderness therapy, one therapist treats many clients simultaneously. The results indicated that a therapist who treats many clients simultaneously can have different levels of alliance with each client, and that therapeutic alliance was a significant predictor of positive client outcomes (Marcus et al., 2011). In their discussion, the researchers highlighted the idea that the factors affecting and affected by therapeutic alliance are difficult to measure with any certainty, as it is possible that the same characteristics that allow clients to build strong alliances with therapists may also lead to better treatment outcomes. Further research is needed that addresses these limitations of therapeutic alliance in order to better understand the extent of its relationship to positive client outcomes.

Residential programs offer clients the opportunity to develop therapeutic relationships with staff members who can serve the function of a substitute parent figure (Manso et al., 2008; Moses, 2000). In a qualitative study that examined residential staff members’ relationships with adolescent clients, Moses (2000) emphasized the significance of attachment theory as it pertains to the relationships between clients and residential staff who can function as both parent and therapist. The relationships that residential staff members form with clients can therefore be rather intense and encompassing, and Moses suggests that residential staff can be even more influential than therapists because their presence in clients’ lives can make more of a lasting impression. Attachment theory also emerged in a qualitative, exploratory study by Manso, Rautkis, and Boyd (2008), in which focus groups were conducted with male youth in a wilderness therapy program. Many of the young men described the staff members as father figures and were likely to attach parent-like qualities to their descriptions of the staff members with whom they had formed close alliances. In both studies, the importance of prioritizing staff-client relationships was emphasized because they can prove to be corrective attachment experiences for youth in residential settings (Manso et al., 2008; Moses, 2000). In most cases, clients are referred to wilderness therapy in part because of family issues that parents do not feel equipped to handle at home (Harper & Russell, 2008). Thus, clients’ relationships with guides have the potential to be powerful mediums through which clients can work through some of the challenges they are experiencing with their primary caregivers.

While relationships can lead to powerful long-term change for clients, therapeutic alliance may be most important in the early stages of treatment, especially with regards to client retention and general buy-in (Bhati, 2014). In an attempt to rule out variables such as prior improvement and patient characteristics in order to determine the actual significance of therapeutic alliance in predicting client outcomes, Klein et al. (2003) looked at therapeutic alliance in clients with depression who were being treated with a cognitive-behavioral analysis system of psychotherapy (CBASP). Some clients were treated with CBASP alone, while some received a combination of CBASP and medication. The analysis indicated that for all clients in both groups, early alliance was a strong predictor of change (Kelin et al., 2003). Similarly, Bickman et al. (2004) also found early alliance to be a strong predictor of change. Their longitudinal study assessed perceptions of therapeutic alliance by youth and staff members at a therapeutic wilderness camp and found that youth and staff members tended to have different perceptions of the strengths of their relationships, and that alliance in the early stages of treatment was an important predictor of positive client outcomes. Bickman et al. (2004) hypothesized that there may be certain staff characteristics that predict therapeutic alliance, and suggested the need for further research in this area. Forming a better understanding of what these characteristics are and the impacts they have on therapeutic alliance could allow the field of OBH to make better informed decisions with regards to hiring guides and matching them with specific clients and client groups.

Gender Matching

Knowing that therapeutic alliance is important and that building alliance quickly may be especially important, it is vital to further examine factors such as gender matching that may facilitate therapeutic alliance.  Wintersteen, Mensinger, and Diamond's (2005) study looked to see whether gender and racial differences between clients and therapists affect therapeutic alliance and treatment retention. Their results indicate that client-therapist pairs matched by gender reported higher levels of alliance, which generally led to greater retention and better outcomes for both male and female clients (Wintersteen et al., 2005). Wintersteen et al. (2005) emphasized the importance of recognizing adolescence as a period of development in which gender identity is of peak significance; hence adolescents may be more focused than clients in other developmental stages on the gender of their therapists and residential staff.  Despite these findings, more recently Bhati (2014) conducted a naturalistic study of therapist-client dyads in order to test the hypothesis that gender matching is more important for clients in the early stages of alliance than later in treatment, but this hypothesis was not supported. Bhati’s (2014) research found that there was a tendency for both male and female clients to report higher levels of alliance with female therapists than with male therapists, suggesting a sort of “female effect” across the board.

This finding parallels an observation about gender’s role in the outdoor education experience, in which both male and female participants rated their relationships with female instructors to be stronger than those with male instructors (Neill, 1997). Neill (1997) also found that female participants tended to rate instructors more favorably in all of the assessed categories than their male counterparts. Neill (1997) attributed both phenomena to a tendency for females to be more focused on interpersonal relationships than males generally are, and he addresses the need for outdoor education to examine its gender biased practices and perhaps add greater emphasis to meeting the disparate needs of male and female instructors. Staff training in OBH programs that explicitly addresses gendered differences in leadership and communication styles could allow for improved guide-client therapeutic alliances across genders.

            Field guides in wilderness therapy serve not only the functions of therapist and/or parent, they also can be seen as role models.  Role models provide people with examples of the kind of success they may achieve in the future, and as such, young people often seek a sense of belonging through relationships with role models (Lockwood, 2006). Although no research in wilderness therapy has looked specifically at this relationship, a study by Lockwood (2006) supported the hypothesis that same-gender role models tended to have greater influences on college students’ self-perceptions. Lockwood (2006) also found that females had a greater tendency than males to seek same-gender role models. In the context of wilderness therapy, it may be the case that gender plays a more significant role in the formation of therapeutic alliance for female clients than for their male counterparts. Thus, it may be more important for female clients to be matched with same-gender guides than it is for male clients. OBH programs could improve outcomes for female clients by intentionally providing them with exposure to role models who share gender and other demographic characteristics.

Many OBH programs emphasize the importance of creating as much of an equal playing field between clients and field guides as possible, in order to increase the influence that guides can have in pushing clients toward higher levels of functioning. Guides typically use the same equipment, eat the same food, sleep under the same kind of shelter, and are subjected to the same elements and potentially challenging living conditions as clients. As such, guides exist somewhere in the gray area between therapist and peer, and this position is especially powerful in work with adolescents. Adolescents may see guides as proxies on which they can base their perceptions of their own present and future capabilities. Wheeler, Martin, and Suls (1997) described the proxy model of social comparison as a means by which people assess their ability to complete certain tasks based on the abilities of others who they perceive as similar to themselves. Martin, Suls, and Wheeler (2002) found that people look for proxies who share similar attributes to themselves in relevant areas. For example, if an adolescent girl were attempting a physically demanding primitive fire starting skill for the first time, she might decide that she will be able to complete the task based on having observed another adolescent girl whose upper body strength and coordination she perceived to be similar to her own. She may not deem herself capable of the task on the basis of watching an adult male complete it successfully, because the adult male is not perceived as an accurate representation of herself.

            The proxy model could be useful in thinking about whether wilderness therapy clients might benefit more or less from being matched with guides of the same gender. Suls and Wheeler (2002) did not address gender as one of the attributes toward which people gravitate when choosing a proxy for social comparison. Further research that addresses the relevance of gender to the proxy model would be helpful in deepening the discussion about the relationship between wilderness therapy clients and guides. It may be the case that clients look to guides for information about their own capabilities, and that sharing demographics such as gender could be important to clients in assessing their own self-worth.      

Conclusions

The available literature suggests that some relationship exists between gender and therapeutic alliance. Therapeutic alliance is important for wilderness therapy clients, and it is likely to be important for field guides as well. Bunce (1998) found that wilderness therapy guides are likely to burn out at slower rates when they feel personally connected to their clients; hence, understanding the factors that contribute to therapeutic alliance may be beneficial to both clients and field guides. A study is needed to address the complexities of gender and therapeutic alliance within the specific realm of wilderness therapy. Such a study would fill some of the existing research gaps by linking what is known about the unique role of residential staff in clients’ experiences with what has been examined in regards to gender matching for client-therapist and student-role model dyads. Based on the above studies, it seems likely that client-guide gender-matching may be more important for female clients than for male clients in terms of developing strong therapeutic alliances. It could also be the case that certain clients benefit more from cross-gender relationships because of the specific nature of their therapeutic needs, in particular with regards for the need that many clients experience for corrective attachment experiences. Based on their previous difficulties or disruptions in attachment, clients may find a corrective experience with a guide who is of the same gender of their prior attachment figure.

Regardless of the specific treatment goals of each client, the literature suggests that therapeutic alliance is often stronger when clients share demographic similarities with their therapists and residential staff. Gender may be one of many demographic realms in which clients seek a sense of belonging with guides, and it is not clear where gender may fall in order of significance relative to other factors such as race, socioeconomic background, geographic place of origin, personal interests, sexual orientation, and others. To date is it unclear the exact role that field guides play in the change experiences in wilderness therapy clients. Further research is needed that looks specifically at field guides in order to develop best practices that may better guide programs in making staff and programming choices that align with client needs and potential for success.

For now, the research indicates that OBH programs would be well served in emphasizing the formation of therapeutic alliances between guides and clients. Programs could approach such an emphasis in a number of ways, including the training they provide to guides and the decisions that they make in placing certain guides with certain groups of clients. Transparent dialogs about the ways in which guides’ and clients’ experiences are affected by gender could add richness to in-service trainings by shedding light on what it means for guides to enter the field and attempt to ally themselves with clients of the same or opposite gender. Those in charge of making staffing decisions in OBH programs may be able to facilitate greater therapeutic alliances by focusing on which guides are most likely to connect with which clients on the basis of sharing gender, race, socio-economic status, or other traits. They could also improve the overall awareness factor among guides by explicitly discussing the intentionality behind each staffing decision prior to the start of the shift. OBH programs are likely already doing this, but perhaps could be better informed about the effects that staffing decisions have on client outcomes.

 

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