Risk Management in Adventure Therapy

Having policies and procedures in place for risk management is critical for any organization to operate effectively. Guidelines for risk management related to adventure activities are well documented and will not be explored here. The focus of this section is on operational standards for risk management as they relate to AT. Adventure therapy provides a risk-rich environment that can allow for emotional growth as long as the risk is well-managed. Organizations operate under differing philosophical paradigms and will have differing risk management needs as a result of this. Some organizations will have a higher level of acceptable risk than others, whether discussing activity selection or the types of clients to be served. However, when an organization takes on the role of providing adventure therapy, this narrows the field of acceptable risk because the ethical requirement for providing any therapy is to do no harm. Risk management decisions in AT are made in accordance with ethical standards of practice and organizations, programs and practitioners are expected to balance the level of acceptable risk effectively to limit the risk of doing harm to clients in their care.
Best practice is to have a culture of awareness that risk management is critical to the services provided and investment in the processes set in place to manage risk. The needs of clients, skills of staff, and the activities utilized will influence the amount of risk that is appropriate for any adventure therapy service. Everyone involved in the provision of service - staff, practitioners, clients, management, etc is a partner in the process of managing risk. Know which populations or diagnostic issues you can serve effectively and which you cannot. Ensure that practitioners are educated in what is best practice for the clinical issues and populations you are providing service for.
Some topics related to risk management have aspects that need addressed as they relate to providing adventure therapy.

Emotional Safety and Trauma
Although AT is a powerful tool for intervention and positive change, the potential to traumatize or re-traumatize clients in adventure therapy can be high if the risk is not managed well. Therefore, it is of paramount importance for organizations, programs and practitioners to have established risk management plans in place that reduce the potential for causing trauma to clients. Each decision made in the course of providing AT, whether that is in admission, assessment, intervention, or discharge should weigh the possibility that a client may be harmed or traumatized, intentionally or unintentionally. If the likelihood for trauma is anything but low, decisions should be made that err on the side of caution to protect the best interests of the client. In addition to needing policies and procedures in place, staff training in the provision of trauma-informed care is critical when providing services to clients who have experienced trauma. Potential areas for trauma in AT are readily available - the use of escorts for assisted admissions, participation on a high ropes course, coping with extreme weather, waiting long periods to eat for clients who have dealt with neglect, or blindfolding participants are just a few examples. Additionally, the potential for trauma is largely dependent on the perspective of the individual affected. This means that the client assessment and their participation in treatment planning becomes even more critical in managing the risks associated with trauma in AT. Best practice for managing risk related to trauma in AT is to engage the client in the process, consider trauma carefully in clinical decisions, and train staff appropriately to assess and respond to clients.

Involuntary Clients and Noncompliance
Client self-determination and voluntary participation in treatment is central to ethical codes related to providing therapy, yet mental health services in the US frequently deal with mandated and involuntary clients. This situation is not unique to adventure therapy, providing AT practitioners with professional guidelines for dealing with involuntary clients and noncompliance that are drawn from mental health fields. It is clear, for example, that it would be unethical to restrain a client for noncompliance. Physical restraints are to be used only as a last resort, when all other resources have been exhausted, to maintain safety when a client is placing him or herself or someone else in immediate danger.
Many AT activities involve a higher level of risk when a client is non-compliant with following safety instructions or maintaining physical or emotional safety for other participants. Travel in the backcountry, high elements such as high ropes, or initiatives activities such as trust fall require some level of client compliance in order for participants to engage safely. AT practitioners must assess clients and facilitate activities carefully so that risk is managed and clients are compliant at an acceptable level.

Best practice for AT is to maximize client investment in the process by working collaboratively with the client in developing the goals and direction of treatment. This is not always possible due to the range and severity of client needs, but practitioners can continue to strive to meet this standard as it is likely to lead to improved client outcomes and higher quality client care while minimizing the risks involved when engaging in more adversarial relationships with clients.
Organizations, programs and practitioners are expected to have policies and procedures in place that effectively manage the risks associated with noncompliance, involuntary clients, and the expected response to these issues so the risk of doing harm is reduced and client care can be improved.

Clinical Crisis Management
Clients may present with many different types of crisis situations in which their ability to cope with stressors becomes overwhelmed and they lose control of their behavior. A crisis situation presents both an opportunity for growth or an opportunity to damage clients, depending on how practitioners respond. Examples of crisis situations include client's engaging in physical aggression, running away, suicide ideation or attempts, experiencing psychosis, or destroying property.
In adventure therapy settings, particularly as services become more remote, significant consideration must be given to how crisis situations will be managed in order to do no harm. Best practice is that risk management plans are in place to deal with anticipated or unanticipated crisis situations, that clients are informed about their role in crisis management and engaged in planning for anticipated problems, and that AT practitioners are trained in crisis management techniques appropriate for the populations with whom they interact. In wilderness settings, it is particularly important to consider the ability of the organization, program or practitioners to manage clients in crisis in remote settings without doing harm to the client. It has clearly been demonstrated that this can be done with careful planning, training and implementation, but providers of these services are cautioned to maintain a focus on managing this risk effectively so that client care does not suffer.

Client Removal or Program Extension
Practitioners are faced with making decisions about client services related to removal from services or extending services beyond an initially agreed upon length of time. Policies and procedures related to client removal or program extension that account for available resources, staff skills, and ability to manage the issues presented by clients are an important part of managing risk in programs. Organizations, programs and practitioners need to have a clear idea of the severity of client issues that can be managed by the services provided and follow identified criteria in making these clinical decisions. If a client presents a significant risk of harm to self or others, program removal must be considered. The guidelines for making these decisions will vary considerably depending on the type and structure of services provided, resources available and training and experience of the practitioners. Best practice for managing this risk is to have clearly documented guidelines, policies and procedures that account for all of the above mentioned variables.