Long-Term Evaluation of an Australian Peer Outdoor Support Therapy for Contemporary War Veterans

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Long-Term Evaluation of an Australian Peer Outdoor Support Therapy for Contemporary War Veterans

S Cloete / L Chantler *

Keywords : contemporary war veterans, peer outdoor support therapy, Trojan’s Trek, post-deployment

Citation Information : Eat, Sleep, Work. Volume 3, Pages 39-53, DOI: https://doi.org/10.21307/esw-2020-003

License : (CC-BY-NC-ND 4.0)

Published Online: 05-September-2020

ARTICLE

ABSTRACT

War veterans experience psychological disorders as a result of deployment. Peer outdoor support therapy (POST) may be an alternative or complementary therapy, as part of the larger field of complementary and alternative medicine (CAM), to traditional psychological approaches for the treatment of psychological disorders arising from deployment. The long-term benefit of Trojan’s Trek, an Australian POST, was evaluated for its benefits on wellbeing, depression, anxiety, and stress. Nine male participants who participated in Trojan’s Trek during 2013 completed four self-report questionnaires across four time-points, as follows: General Perceived Self-Efficacy Scale (GSE), Life Satisfaction Questions (LSQ), Positive and Negative Interactions Scale (PNI), and Depression Anxiety Stress Scales short-version (DASS-21). Questionnaires were administered pre-Trek, immediately post-Trek, at 2-3-month follow-up, and 9-month follow-up. The resultant data were analyzed using Reliable Change Indexes (RCI). Depression, anxiety, and stress decreased, and wellbeing increased, post-trek. Reliable decreases for depression, anxiety and stress, and reliable increases in Self-Efficacy were observed post-trek. Positive outcomes for participants were achieved immediately post-Trek and over a nine-month period. POST may supplement current empirically supported psychological treatments for psychological disorders arising from deployment.

Graphical ABSTRACT

1. Introduction

Each year in Australia, approximately 12,000 Australian Defence Force (ADF) personnel are deployed in military service (1). Mental health problems including Post-traumatic Stress Disorder (PTSD, i.e., a set of symptoms such as traumatic flashbacks, avoidance, feeling emotionally numb, negative thoughts and mood, and agitation) (1,2), anxiety (3) and depression (1) may develop in some personnel as a result of exposure to traumatic experiences during such service. In addition, first responders and emergency services are also at risk for developing similar mental health problems due to the nature of their work (4, 5).

Unfortunately, traditional approaches to mental health care are not effective for all veterans (3, 6, 7). This is possibly due in part to the perception of shame attached to asking for help, where mental illness is treated as weakness or worse, dismissed as malingering (8, 9). Yet another pertinent factor may be trust issues related to whether the therapist can comprehend the unique difficulties of a soldier (8). Other factors preventing veterans from accessing help may be the lack of services near their residences, difficulties with readjustment, stressors such as financial pressures, and the loss of consistent communication with military comrades due to geographic separation post-deployment (8, 10).

Thus, peer support programs provide an alternative approach to traditional mental health treatments. Typically, peer support involves two or more individuals sharing a socially and emotionally supportive interaction (11). Peer support has proven effective in both non-veteran populations (12-14) and veteran populations (1, 15-19). However, there are few veteran peer support studies that examine the long-term effectiveness of such interventions.

Outdoor therapy is another approach to mental health care. Outdoor therapy involves exposure to natural outdoor environments (20) for therapeutic purposes. Outdoor therapy has proven effective in non-veteran populations (21-24) and in veteran populations (25-27) but the long-term benefits are unclear.

Peer outdoor support therapy (POST) combines both peer support and outdoor therapy elements and offers a promising CAM approach to pharmacology and trauma-focused psychological interventions following deployment (28). POST also incorporates techniques from cognitive-behavioural therapy (CBT) which is an evidence-based short-term structured psychotherapy aimed at problem resolution and adapting maladaptive thoughts and behaviours to become more helpful (29). POST increases accessibility to treatment by engaging individuals who are hesitant to seek help (21) or who have dropped out of alternative treatments (30). Combat veterans experiencing PTSD may benefit from group outdoor therapy by demonstrating improved wellbeing. Veterans involved in POST programs have reported increased confidence, physical and emotional safety, perceived success, leadership, teamwork skills, compassion, respect for others, and responsibility acceptance (31).

In general terms, the current literature suggest that POST may be effective in the veteran population (30-34) but research concerning the long-term benefits is needed.

Trojan’s Trek, a South Australian POST, incorporates peer support and outdoor environments to provide contemporary war veterans (those who have served in recent wars or conflicts) with psychological support. Trojan’s Trek has been assisting contemporary veterans through individual and group challenges since 2009. Peer mentors (veterans who have experienced and overcome similar challenges and are trained and accredited to deliver Trek program material) educate Trekkers about individual strategies that encourage positive change and enhance self-esteem (35). The Australian Centre for Posttraumatic Mental Health (32) conducted an independent evaluation of the 2009 Trojan’s Trek with a 2-month follow-up. They found that the Trek had beneficial outcomes for participants at the conclusion of the Trek and after two months. Additionally, Bird (36) assessed the 2-3 month follow-up of questionnaire results from the 2010 to 2012 Trojan’s Trek groups, finding similar beneficial results, and recommended a long-term evaluation including a 9-month follow-up. Trojan’s Trek conducted a 9-month follow-up study which provided archival data for use in the current study.

The purpose of this study, therefore, was to assess the longer-term effects of participation in Trojan’s Trek for 2013 Trekkers, with a 9-month follow-up of participants’ wellbeing, depression, anxiety, and stress given that previous studies have only assessed up to three months post-intervention.

2. Methods

2.1. Participants

Background and demographic variables

An archival convenience sample of nine men involved in a recent Trojan’s Trek was utilized. Participants were 22-43 years of age. Only male participants were involved in the study. In addition to eight veteran participants, a non-veteran was involved in the Trek. The Victoria Ambulance participant was accepted based on experience commonality, including PTSD symptomatology and similar negative mental health outcomes.

The recruitment process

Trojan’s Trek participants self-selected as a result of their negative mental health post-deployment experiences. Participants were recruited by referrals of past trekkers. Participants volunteered to complete questionnaires for Trojan’s Trek and gave consent for the archival data to be used in research.

Attrition rates

Nine participants provided questionnaire data pre-Trek (baseline), immediately post-Trek, and at 9-month follow-up (100% return rate). Seven participants provided questionnaire data at 2-3 month follow-up (77.7% return rate). Missing data were replaced with values calculated using mean substitution and interpolation, to maximise data from the small sample.

Inclusion and exclusion criteria

The target group of Trojan’s Trek is male contemporary veterans who self-select to participate as a result of post-deployment mental health issues. Female veterans and those with medical conditions requiring proximity to medical services were excluded from the Trek which is undertaken in a remote location.

2.2. Design and Analysis

Questionnaire data was collected from the nine participants at four time points (pre-Trek, immediately post-Trek, 2-3 month follow-up, and 9-month follow-up). Analysis of individual participant scores on questionnaires over time was assessed using Reliable Change (RC) calculations (37). RC compares pre- and post-intervention scores to determine whether an individual’s positive or negative results reflects meaningful change (i.e., whether any observed change is outside of the expected bounds of typical variation for that measure).

2.3. Materials and Measures

Questionnaires

Trojan’s Trek routinely administers four self-report questionnaires to evaluate the effectiveness of the program.

Life Satisfaction Questions (LSQ) from the Household and Income Labour Dynamics in Australia survey (HILDA) (32). The LSQ is a 13-item questionnaire measuring quality of life in 13 domains on a 10-point Likert scale ranging from 0 (dissatisfied) to 10 (satisfied) (32). LSQ reliability was found to be α=0.73 (38). Questions include life satisfaction in “the home in which you live” and “your current sleep pattern” (32). Scores across items are summed for a total score of life satisfaction. The larger the score, the greater the individual’s overall life satisfaction (minimum=0, maximum=130).

General Perceived Self-Efficacy Scale (GSE) (39). The GSE is a 10-item questionnaire measuring self-efficacy and self-belief through the applicability of statements with a 4-point Likert scale ranging from 1 (not at all true) to 4 (exactly true). Statements include “I can solve most problems if I invest the necessary effort” and “If someone opposes me, I can find means and ways to get what I want”. Scores across items are summed for a total general self-efficacy score. The larger the score, the greater the individual’s overall general self-efficacy (minimum=10, maximum=40).

Positive and Negative Interactions Scale (PNI) (40). The PNI rates perceived relationships with family, friends, and spouse in 14 items with responses on a 4-point Likert scale ranging from 4 (often) to 1 (never). Questions include “How often do friends make you feel cared for?” and “How often do you have an unpleasant disagreement with your partner?” (40). Each domain (i.e., friends, relatives, and partner) subscale is separated into positive and negative interactions for a total of six subscales. Friends and relatives subscales have a minimum score of two and maximum of eight. Partner subscales have a minimum score of three and a maximum of twelve.

Depression Anxiety Stress Scales short-version (DASS-21) (41). The DASS-21 is a shortened version of the Depression Anxiety Stress Scales full-version (DASS-42) with a similar factor structure and providing similar results (42). The DASS-21 comprises three subscales for depression, anxiety, and stress across 21 items, as measured on a 4-point applicability Likert scale. Scores range from zero (did not apply to me at all) to three (applied to me very much, or most of the time). Scores on subscales range from a minimum score of zero, to a maximum of 42. Items include “I couldn’t seem to experience any positive feeling at all” and “I experienced trembling (e.g., in the hands)” (41). DASS-21 raw scores are multiplied by 2 to enable comparison with the DASS-42 psychometric properties. Scores for depression, anxiety, and stress are summed from the relevant items and compared to DASS-42 severity ratings.

2.4. Procedure

Program Description of Trojan’s Trek. Trojan’s Trek is an annual 6-day South Australian POST held in the Northern Flinders Ranges. Trekkers spend three nights camping and travelling in the Flinders Ranges. The first and last nights are spent at Moolooloo Station. The Trek incorporates a range of different psychological approaches within its program structure including CBT-based group sessions, skill building activities, informal gatherings and one-on-one debriefing activities. Trojan’s Trek is drug and alcohol free and is funded by private and corporate donations and the South Australian Department of Health.

Data Collection. Trojan’s Trek requires participants to individually complete questionnaires pre- and immediately post-Trek in a group setting. Paper copies of follow-up questionnaires (at 2-3 and 9-months) are mailed to participants with a postage-paid return envelope. Participants are asked to complete the four questionnaires within a 2-week timeframe in their choice of setting. The University of South Australia Human Research Ethics Committee exempted this study from ethics approval because it used archival data.

2.5. Statistical Analyses

The Reliable Change Index (RCI) was used to examine the data for each of the nine participants. The RCI tells us whether change reflects real change or fluctuations expected as a result of the standard error of measurement for the particular test being used (37). Questionnaire results from immediately post-Trek, 2-3 month follow-up, and 9-month follow-up were compared to baseline measures using RCI calculations where the necessary statistical information was available.

The test-retest reliability of 0.47 (for men) was used to calculate RCIs for the GSE. Test-retest reliability was unavailable for the DASS21, however, it was available for the DASS (42-item version) (r=0.71, r=0.79, and r=0.81 for depression, anxiety, and stress respectively) (43). By multiplying results on the DASS21 by two, scores became comparable to the DASS-42 (41, 44). Test-retest reliability information was not available for LSQ and PNI and so RCI calculations were not conducted. Instead, general comments are made about these findings.

3. Results

3.1. Depression, Anxiety, and Stress

Table 1 shows means (and standard deviations) for DASS21 scores at each measurement point. Mean scores for Depression and Stress Subscales were in the severe range pre-trek, and were in the normal to mild range throughout follow-up. Mean scores on the Anxiety subscale were in the extremely severe range pre-trek, and were reduced to the moderate range throughout follow-up.

Table 1.

Descriptive Statistics for Depression, Anxiety, and Stress Subscales in the DASS-21 (n=9). The severity band for the mean scores is also indicated.

10.21307_esw-2020-003-tbl1.jpg
10.21307_esw-2020-003-f001.jpg

Figure 1 shows a stacked bar graph of the distribution of DASS-21 scores across severity bands at each measurement point. Pre-trek, nearly 80% of participants reported severe or very severe levels of Depression, anxiety and Stress, which was reduced post-trek, remaining at less than one third of participants throughout follow-up (as indicated by the dashed line, Figure 1).

Figure 1.

Stacked bar graph of distribution of depression (left), anxiety (centre) and stress (right) ratings by severity band (as outlined in (41)). Percentage of participants in each band is displayed pre-trek, immediately post-trek (0m), 2-3months post-trek (2-3m) and 9months post-trek (9m). Depression severity ratings: Extremely severe 28+, Severe 21-27, Moderate 14-20, Mild 10-13, Normal 0-9. Anxiety severity ratings: Extremely severe 20+, Severe 15-19, Moderate 10-14, Mild 8-9, Normal 0-7. Stress severity ratings: Extremely severe 34+, Severe 26-33, Moderate 19-25, Mild 15-18, Normal 0-14.

10.21307_esw-2020-003-f002.jpg

Figure 2 (first three panels) displays results of the Reliable Change analyses for DASS-21 measures. A reliable decrease in Depression occurred for 67% of the sample immediately post-trek and at the 2-3m follow-up. This decrease was maintained by 44% of participants at 9 months. Anxiety was reliably reduced for 78% of participants throughout follow-up. Stress was reliably reduced in 78% of participants at 0 and 2-3 months, and maintained in 67% at 9 months. No participants experienced a reliable increase in DASS-21 measures.

Figure 2.

Stacked bar graph of distribution of depression, anxiety, stress and self-efficacy ratings by reliable change from pre-trek measurement. Percentage of participants showing a reliable decrease (dark blue), no change (white) or a reliable increase (light blue) is shown, relative to pre-trek scores, immediately post-trek (0m), 2-3months post-trek (2-3m) and 9months post-trek (9m). As an example, the lower far right panel illustrates calculation of reliable change for a single variable (depression) at a single time point (0m post-trek, y-axis) compared to pre-trek (x-axis). The central diagonal line is drawn at x=y, or no change from pre- to post-trek. The upper and lower diagonal lines represent x=y ±the reliable change index (RCI). Points falling above this zone represent a reliable increase, and below, a reliable decrease, in scores. The dark blue bars for depression, anxiety and stress represent reliable decreases in these variables. The light blue bars for Self-Efficacy represent reliable increases.

10.21307_esw-2020-003-f003.jpg

3.2. Wellbeing

Table 2 shows means (and standard deviations) for wellbeing measures at each measurement point. All measures demonstrated improved wellbeing following the trek.

Table 2.

Descriptive Statistics for Wellbeing Measures (n=9).

10.21307_esw-2020-003-tbl2.jpg

The only wellbeing measure with sufficient published statistics to calculate reliable change was Self-Efficacy.

This is displayed in the final panel of Figure 2. Self-Efficacy scores increased for approximately half of the sample during follow-up. No participants experienced a reliable decrease in self-efficacy.

Figure 3 displays the simple change in the remaining wellbeing measures at each of the post-trek time points. The top panel of Figure 3 shows the positive wellbeing parameters. Immediately post-trek, one third of participants reported an increase in positive friend relationships, which increased to nearly 90% at 2-3 months and 100% at 9 months. One third of the sample reported an increase, and 44% reported a decrease in positive family relationships post-trek. This was consistent throughout follow-up. An increase in positive partner relationships was seen for 44% of participants immediately post-trek. This increased to 56% at 2-3 months, dropping to 22% at 9 months. Life satisfaction was increased for 67% of participants. This was consistent throughout follow-up.

Figure 3.

Stacked bar graph of distribution of friend, family, partner and life satisfaction ratings by simple change from pre-trek measurement. Percentage of participants showing a decrease (dark blue), no change (white) or an increase (light blue) is shown, relative to pre-trek scores, immediately post-trek (0m), 2-3months post-trek (2-3m) and 9months post-trek (9m). The top panel shows positive relationship measures and life satisfaction and the lower panel shows negative relationship measures. The predominantly black bars for positive friend, family and partner interactions and life satisfaction represent increases in these variables. The predominantly dark blue bars for negative friend, family and partner interactions represent decreases.

10.21307_esw-2020-003-f004.jpg

The lower panel of Figure 3 shows the negative wellbeing parameters. Nearly 80% of participants reported a decrease in negative friend relationships at 0 months and 2-3 months post-trek. This reduced to 67% at 9 months. Nearly 80% of participants reported decrease in negative family relationships at 0 months. This reduced to just over half at 2-3 months and one third at 9 months. Nearly 80% of participants reported decreases in negative partner relationships at 0 months, 100% at 2-3 months, returning to 80% at the end of follow-up.

4. Discussion

This study is the first long-term evaluation of an Australian POST program to date, and more specifically the first long-term evaluation of Trojan’s Trek. The maintenance of reductions in depression, anxiety and depression and an increase in self-efficacy over a nine-month period arising from involvement in Trojan’s Trek suggests that POST may be a useful adjunct to traditional psychotherapies. POST provides opportunities for veterans to feel connected to others including those in the emergency services who have served and who have shared traumatic experiences. It provides opportunities for conversation, leadership and teamwork in an emotionally and physically safe environment (31). These mechanisms may have contributed to positive results.

The variability of the PNI and LSQ results may be attributed to a vast array of contributing factors outside of the influence of Trojan's Trek. Life Satisfaction is a broad construct and as such it is influenced by a broad range of factors. A short-term Trek may not be sufficient to impact on the broad range of concerns covered by the LSQ. Likewise, the PNI formed part of the archival data made available. The poor psychometric properties of this tool and its unclear questions mean that any data analysis was likely to be problematic. Additionally, the questions of the PNI focus on relationships between “friends” and while one of the defining features of the Trek is its group format and focus on group members being emotionally supported by other veterans, they may not have considered fellow Trekkers as friends after such a brief encounter. Thus, it is unsurprising that the Trek did not appear to have any discernable benefits on Trekkers relationships. Perusal of the data suggests that Trekkers reported varied levels of happiness in their relationship pre-Trek and that this did not change meaningfully following the Trek.

The current research supports previous findings for POST as being beneficial in a veteran population (30, 33, 34, 45). Trojan’s Trek utilizes similar therapeutic approaches to the Outward Bound Veteran Program (OBVP) (31, 45, 46) and Rivers of Recovery (ROR) programs (47), by running activities in remote environments for groups of veterans. Trojan’s Trek is thought to ease post-deployment transition for veterans similarly to OBVP (46) and ROR (47).

Results support previous findings demonstrating clear benefits for Trojan’s Trek participants (32, 36) with similar findings to Bird (36), showing wellbeing and mental health improvements immediately post-Trek, and at follow-ups. This research extends on current knowledge about Trojan’s Trek, by confirming that there are long-term benefits for participants 9-months post-trek.

4.1. Limitations and Future Research

The small sample size means that the generalizability of results to the overall veteran population is limited. Sample size limitations could be overcome in future studies by integrating Trojan’s Trek participant groups across different years into a single sample for analysis. Missing data-points further decreased available data for analysis. Methods of mean substitution and interpolation were implemented to maximise the available data-set. These methods may have influenced the results.

The absence of a control group further limits the study. The archival nature of the data meant that it was not possible to include a control group. Future studies could include a matched wait-list control to help determined whether the passing of time alone had a healing effect on participants rather than therapeutic components related to Trojan’s Trek.

External factors or life circumstances may have influenced questionnaire scores, especially at 2-3 and 9 month follow-ups. Trekkers may have been undergoing other therapeutic interventions between the conclusion of the trek and follow-up and it was not possible to assess whether the observed positive changes resulted from the Trek alone or from additional treatments. It is also possible that Trojan's Trek is self-selective in that those who agreed to participate may be more likely to engage in therapy as a whole. As Trojan’s Trek is alcohol and drug free, positive changes experienced by veterans during the trek may be attributable to the break from these substances. Future studies should further assess these potential influencing factors.

The assessment tools chosen by Trojan’s presented problems during analysis. Neither the PNI nor the LSQ have sound psychometric properties, meaning that the validity and reliability of these tools is unknown. The varied PNI results may have come about as a result of the questionnaire itself, rather than a lack of positive outcome from the Trek. The current researchers have encouraged Trojan’s Trek to use more psychometrically sound and well-regarded assessment tools to improve the meaning of results, as the PNI and LSQ lacked comprehensive psychometric properties and scoring instructions.

4.2. Study Strengths

The current study is the first long-term evaluation of an Australian POST program to date, and more specifically the first long-term evaluation of Trojan’s Trek. The results provide limited support for the effectiveness and benefits of Trojan’s Trek for contemporary post-deployed war veterans. Given the fact that only one group has run annually to date, the feasibility of running additional and more regular groups should be considered. Having rapid access to a Trojan's Trek group would improve the accessibility and hence the likely effectiveness of this approach to assisting traumatised veterans.

The fact that the researcher did not become actively involved in the data collection from participants and so did not contaminate the underlying focus on peer relationships in Trojan’s Trek increases confidence in the conclusion that it was the peer relationships rather than the presence of the researcher that led to the observed benefits. Rapport and trust relationships were established between participants and staff and the researcher did not disrupt this. It is likely that participants would not have been as open in their personal sharing with an independent researcher as they were with Trojan's Trek staff.

A further strength was that the study did not only consider group statistical differences, but also the clinical significance of Trojan’s Trek for individuals. RCIs were used to determine clinical significance and determine a greater meaning of results where possible despite the small sample size.

Despite limitations associated with the questionnaires that Trojan’s Trek administered to participants, the questionnaires were quick to complete with questions that were easy to understand, consequently minimising participant burden. It is estimated that the four questionnaires took approximately ten minutes to complete.

Findings have great applicability in assisting war veterans who are experiencing difficulty reintegrating back into society. This research has the potential to help veterans who are struggling to find appropriate mental health care for psychological issues.

4.3. Conclusions

Results of the current study lend support to POST as an alternative or complementary treatment for post-deployed veterans. Previous research (28) showed positive results over a three-month period. The current researchers showed that these benefits could be maintained over a longer period of time. This suggests that Trojan’s Trek could be considered as a ‘first-step’ treatment approach for veterans seeking psychological assistance.

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  36. Bird K. Contemporary veterans' experience of an Australian peer outdoor support therapy program. Masters Thesis, Trojan's Trek Website, http://www.trojanstrek.com/wp-content/uploads/2014/11/MASTERS-THESIS.Part-One.2013.Literature-Review.Kendall-Bird-2.pdf.
  37. Jacobson NS, Truax P. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology. 1991;59(1):12-9.
    [PUBMED] [CROSSREF]
  38. Lucas RE, Donnellan MB. Estimating the reliability of single-item life satisfaction measures: Results from four national panel studies. Social Indicators Research. 2012;105(3):323-31.
    [PUBMED] [CROSSREF]
  39. Schwarzer R, Jerusalem M. Generalized Self-Efficacy Scale. In J. Weinman, S. Wright, & M. Johnston, Measures in health psychology: A user's porftolio. Causal and control beliefs. Windsor, England: NFER-NELSON; 1995.
  40. Schuster TL, Kessler RC, Aseltine RH. Supportive interactions, negative interactions, and depressed mood. American Journal of Community Psychology. 1990;18(3):423-38.
    [PUBMED] [CROSSREF]
  41. Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. Sydney, Australia: Psychology Foundation Monograph; 2004.
  42. PFA. Overview of the DASS and its uses. Psychology Foundation Australia; 2018.
  43. Brown ID. Prospects for technological countermeasures against driver fatigue. Accident analysis and prevention. 1997;29(4):525-31.
    [PUBMED] [CROSSREF]
  44. Ronk FR, Korman JR, Hooke GR, Page AC. Assessing clinical significance of treatment outcomes using the DASS-21. Psychological Assessment. 2013;25(4):1103-10.
    [PUBMED] [CROSSREF]
  45. Harper NJ, Norris J, D'astous M. Veterans and Outward Bound experience: An evaluation of impact and meaning. Ecopsychology. 2014;6(3):165-73.
  46. Ewert A, Van Puymbroeck M, Frankel J, Overholt J. Adventure education and the returning military veteran: What do we know? Journal of Experiential Education. 2011;33(4):365-9.
  47. Flammang JL. Mending waters: Young veterans find solace, regain confidence on the river. 2011, 17 August.
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FIGURES & TABLES

Figure 1.

Stacked bar graph of distribution of depression (left), anxiety (centre) and stress (right) ratings by severity band (as outlined in (41)). Percentage of participants in each band is displayed pre-trek, immediately post-trek (0m), 2-3months post-trek (2-3m) and 9months post-trek (9m). Depression severity ratings: Extremely severe 28+, Severe 21-27, Moderate 14-20, Mild 10-13, Normal 0-9. Anxiety severity ratings: Extremely severe 20+, Severe 15-19, Moderate 10-14, Mild 8-9, Normal 0-7. Stress severity ratings: Extremely severe 34+, Severe 26-33, Moderate 19-25, Mild 15-18, Normal 0-14.

Full Size   |   Slide (.pptx)

Figure 2.

Stacked bar graph of distribution of depression, anxiety, stress and self-efficacy ratings by reliable change from pre-trek measurement. Percentage of participants showing a reliable decrease (dark blue), no change (white) or a reliable increase (light blue) is shown, relative to pre-trek scores, immediately post-trek (0m), 2-3months post-trek (2-3m) and 9months post-trek (9m). As an example, the lower far right panel illustrates calculation of reliable change for a single variable (depression) at a single time point (0m post-trek, y-axis) compared to pre-trek (x-axis). The central diagonal line is drawn at x=y, or no change from pre- to post-trek. The upper and lower diagonal lines represent x=y ±the reliable change index (RCI). Points falling above this zone represent a reliable increase, and below, a reliable decrease, in scores. The dark blue bars for depression, anxiety and stress represent reliable decreases in these variables. The light blue bars for Self-Efficacy represent reliable increases.

Full Size   |   Slide (.pptx)

Figure 3.

Stacked bar graph of distribution of friend, family, partner and life satisfaction ratings by simple change from pre-trek measurement. Percentage of participants showing a decrease (dark blue), no change (white) or an increase (light blue) is shown, relative to pre-trek scores, immediately post-trek (0m), 2-3months post-trek (2-3m) and 9months post-trek (9m). The top panel shows positive relationship measures and life satisfaction and the lower panel shows negative relationship measures. The predominantly black bars for positive friend, family and partner interactions and life satisfaction represent increases in these variables. The predominantly dark blue bars for negative friend, family and partner interactions represent decreases.

Full Size   |   Slide (.pptx)

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  35. Dunlop LCM. Trojan's Trek: Project report 2013. Trojan's Trek; 2013.
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  37. Jacobson NS, Truax P. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology. 1991;59(1):12-9.
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  38. Lucas RE, Donnellan MB. Estimating the reliability of single-item life satisfaction measures: Results from four national panel studies. Social Indicators Research. 2012;105(3):323-31.
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  39. Schwarzer R, Jerusalem M. Generalized Self-Efficacy Scale. In J. Weinman, S. Wright, & M. Johnston, Measures in health psychology: A user's porftolio. Causal and control beliefs. Windsor, England: NFER-NELSON; 1995.
  40. Schuster TL, Kessler RC, Aseltine RH. Supportive interactions, negative interactions, and depressed mood. American Journal of Community Psychology. 1990;18(3):423-38.
    [PUBMED] [CROSSREF]
  41. Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. Sydney, Australia: Psychology Foundation Monograph; 2004.
  42. PFA. Overview of the DASS and its uses. Psychology Foundation Australia; 2018.
  43. Brown ID. Prospects for technological countermeasures against driver fatigue. Accident analysis and prevention. 1997;29(4):525-31.
    [PUBMED] [CROSSREF]
  44. Ronk FR, Korman JR, Hooke GR, Page AC. Assessing clinical significance of treatment outcomes using the DASS-21. Psychological Assessment. 2013;25(4):1103-10.
    [PUBMED] [CROSSREF]
  45. Harper NJ, Norris J, D'astous M. Veterans and Outward Bound experience: An evaluation of impact and meaning. Ecopsychology. 2014;6(3):165-73.
  46. Ewert A, Van Puymbroeck M, Frankel J, Overholt J. Adventure education and the returning military veteran: What do we know? Journal of Experiential Education. 2011;33(4):365-9.
  47. Flammang JL. Mending waters: Young veterans find solace, regain confidence on the river. 2011, 17 August.

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