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The problems started early on. The young girl from a Denver suburb — identified in a recent lawsuit only as “I.” — had problems interacting with the kids at school. She got bullied.

The oldest of three children, it wasn’t uncommon for I. to fly into a rage once she got home, explaining in graphic detail how she’d kill herself or her siblings.

Therapy, medications, even a stint living with an out-of-state relative didn’t help. Out of options, I.’s parents enrolled her in wilderness therapy, a form of mental health treatment for adolescents that combines traditional therapy with outdoor skills training.

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I. spent almost all of summer 2020 in the program, where she received one-on-one therapy, psychiatric treatment, and a psychological evaluation that added autism and attention deficit-hyperactivity disorder to her list of diagnoses. She made slow but steady progress.

The wilderness therapy and a subsequent stay at a residential treatment facility for girls cost more than $70,000, and I.’s family expected it to be covered the way comparable medical treatments are. But their health insurer refused to pay. First, UnitedHealthcare cited missing information. Then, it said I.’s policy excludes wilderness therapy because it’s considered “experimental.”

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Like dozens of parents before him, I.’s father is turning to the legal system in hopes of forcing payment. It’s an increasingly common move — but one that heaves a formidable question onto judges, who must decide whether the polarizing therapy has enough evidence behind it to warrant insurance coverage.

For every ardent supporter like I.’s father, who claims it helped his daughter, there are passionate detractors who describe lasting trauma from the programs or point to a sordid history. Decades ago, at least 10 kids died under the care of unscrupulous programs — from preventable ailments like dehydration and heat stroke.

“Sometimes it doesn’t go well, and the stakes are very high,” said Andrew Erkis, a former wilderness therapist who founded Stratas Consulting Group, which helps parents choose the best setting for their child. “But remember, these are very tricky kids to work with. You wouldn’t be out there unless you were treatment resistant, for lack of a better term.”

Coverage fights

Wilderness therapy involves a team of guides and therapists taking adolescents with severe behavioral health issues like suicidal ideation and substance abuse into the woods for weeks or months at a time. There — far from phones, friends, and regular lives — they get a mix of traditional psychotherapy and outdoor skills training.

Often, it’s compared to residential treatment facilities. They’re similar in that they both tend to be a last resort for families with struggling adolescents. The teens themselves mostly don’t have a choice in the matter, having been referred either by parents or judges.

Wilderness therapy and residential treatment programs also use similar staffing models. Clients spend most of their time with either field guides, in the case of wilderness therapy, or with support staff, in the case of residential programs. They tend to be young and lack mental health credentials. Psychologists and psychiatrists visit periodically to provide individual and group therapy.

And yet, there’s an important difference: Insurers are much more willing to cover residential treatment. After Congress passed a major law called the Mental Health Parity and Addiction Equity Act of 2008, many insurers removed residential exclusions from their policies, said Mary Covington, who runs a firm called Denials Management that performs claims reviews for patients. Wilderness therapy wasn’t mentioned in the federal law, so those exclusions stayed put, she said. In fact, the exclusions are still tucked into many health insurance plans.

Many of the parents who sue over wilderness therapy, I.’s father included, argue insurers are violating that 2008 law in their refusals to cover it. The law requires plans to cover behavioral health treatments at the same level as comparable medical and surgical procedures.

What makes that legal tactic tricky, though, is it’s hard to find a medical analogue to wilderness therapy, said Mark DeBofsky, an attorney in Chicago who has represented clients in wilderness cases.

“There aren’t any treatments for physical illness where you camp out in the wilderness,” he said.

Another thing that makes these cases difficult to win is they usually involve employer-sponsored health plans regulated by a federal law called the Employee Retirement Income Security Act. ERISA law automatically tilts the cases in favor of the insurers because it puts the burden on the person suing to prove the insurer acted in an “arbitrary and capricious” manner, which is difficult to do.

“The deck is stacked against the claimants from the beginning,” said Brian King, a lawyer in Salt Lake City who has handled dozens of wilderness therapy coverage cases. “That’s just the way it is. It’s very frustrating.”

Yet another barrier to winning is insurers typically only reimburse for treatment from licensed providers, and not all states have licensing programs that include wilderness therapy. Some insurers will only reimburse wilderness providers that are licensed as residential treatment facilities, but not all states license them that way, DeBofsky said. Utah, for example, where many of the programs are located, has a separate licensing program for wilderness therapy.

That said, there have been some wins. In a handful of cases, judges have agreed with parents that the insurers violated mental health parity in refusing to cover wilderness therapy. In one such case, a federal judge said the appropriate medical comparison would be skilled nursing, inpatient hospice, or inpatient rehabilitation.

Plaintiffs have also made headway on the exclusion point. In a lawsuit against Anthem filed in 2017, a federal judge said the insurer was “arbitrary and capricious” in its coverage denial because it didn’t properly define wilderness therapy and didn’t fairly evaluate the specific program in question.

In a 2017 case against Regence and its parent company, another federal judge declined the insurers’ request to scrap a claim that Regence had improperly denied wilderness therapy under ERISA and violated the parity law. In that case, the parties reached a settlement, said Jordan Lewis, the Florida attorney who represented the family that sued Regence.

In denying coverage for I.’s therapy at Open Sky Wilderness Therapy in Colorado, UnitedHealthcare said wilderness therapy is considered unproven for one of I’s diagnoses: attention-deficit hyperactivity disorder. A psychologist at Open Sky had added ADHD to her existing diagnoses, which included depression, anxiety, and mood dysregulation. UnitedHealthcare declined to comment for this story.

In his lawsuit, filed at the end of June, I.’s father, identified in the complaint as “Adam M.,” argues Open Sky’s treatment is not experimental. He shared evidence with the insurer showing that Open Sky is not like the bootcamps of the past that used deprivation and punishment. Instead, he said it’s aligned with professional guidelines and standards.

Adam M.’s lawsuit cites violations of ERISA law and the mental health parity act, arguing the plan covers comparable medical treatments like rehabilitation facilities that it excluded for his daughter.

Building a safer industry

Even as parents fight for coverage, the so-called “troubled teen industry” has a powerful foe: media personality Paris Hilton.

Hilton described in a 2021 op-ed for the Washington Post traumatic experiences at treatment facilities for troubled teens where she says she was choked, slapped, spied on while showering, deprived of sleep, and placed in solitary confinement. In a documentary about her life, Hilton also described being beaten by staff after escaping an “outdoor wilderness program.”

News articles and anonymous internet forums are filled with stories similar to Hilton’s, claiming abuse at both residential treatment facilities and in wilderness therapy.

“There’s a huge contingent trying to shut down and vilify the industry,” Erkis said.

In fall 2021, Hilton, U.S. Rep. Ro Khanna (D-Calif.), and others championed the Accountability for Congregate Care Act, which they said would create standards for such programs and set up an oversight board to handle reports of abuse. It has not yet been introduced in Congress.

What makes this subject especially tricky is even wilderness supporters acknowledge there are still bad actors in their industry. They encourage parents to look closely at the programs’ accreditation and whether they have state licensure.

“It’s kind of cursed the field a little bit to have all these programs that say they deliver but they don’t,” said Michael Gass, director of the Outdoor Behavioral Healthcare Center and a kinesiology professor at the University of New Hampshire. His center’s mission is to improve the industry through research and best practices.

Starting in 2015, wilderness therapy programs began receiving accreditation through an organization called the Association for Experiential Education. AEE’s website lists 22 wilderness therapy programs that have earned its seal of approval. The process entails a multi-day site visit to ensure the programs abide by AEE’s standards. The standards include explicit staff-to-client ratios based on the severity of clients’ mental health conditions, type of activity, and length of program. Programs must have protocols to prevent clients from getting lost or separated from the group and for responding if they do. They have to have both crisis management plans in the event of serious or fatal injuries, and systems for tracking incidents, illnesses, and near misses.

Steve Pace, AEE’s director of accreditations and certifications, said therapy programs aren’t doing the same high-risk activities that adventure programs like Outward Bound do, such as mountain climbing. For therapy programs, accreditation is mostly about ensuring they have the right supervision ratio for camping and hiking and that they’re trained in first aid and risk management.

“You have to create a culture where people feel they can share when something goes wrong,” Pace said. “A fear-based culture is not an educational culture. It can’t be a top-down system.”

Pace thinks wilderness therapy is much safer today than it was in the 90s, when the field was packed with irresponsible programs.

“Back in the day they didn’t know what they were doing,” he said. “There were a lot of fatalities in the 90s.”

A Government Accountability Office report from 2007 uncovered thousands of allegations of abuse and at least 10 deaths at residential treatment programs, including wilderness therapy programs, between 1990 and 2007. The GAO blamed the deaths on a combination of untrained staff who neglected the kids’ needs and inadequate food and equipment.

In one particularly egregious case, a 16-year old named Aaron Bacon developed severe abdominal pain, weakness, and weight loss about 11 days into his stay in a wilderness therapy program in Utah called North Star Expeditions. Staff ignored his pleas for help and instead forced him to continue hiking until he collapsed 31 days into the program. He was airlifted to a hospital and pronounced dead. At the time, he weighed just 108 pounds, 20% less than when he started the program.

An autopsy showed Bacon died of a perforated ulcer, which would have been treatable with early medical attention. North Star was quickly shut down and its owners convicted of criminal charges.

Pace said he’s aware of just three deaths since 2015 in wilderness therapy programs AEE accredits. He said one was a suicide, another was a client who was shot by police after fleeing a program, and the most recent was a client who died during a three- to four-mile hike at a program in Costa Rica. Pace said the medical authorities couldn’t determine the cause of death, and the client had only been in the program four days.

Despite its history, there have been a number of studies showing wilderness therapy to be effective in reducing indicators of depression, anxiety, and other mental health conditions. A 2021 scoping review included 35 peer-reviewed studies of wilderness therapy and found they showed positive effects on a range of psychological, social, and behavioral outcomes.

“The evidence seemed very strong and consistent that there were positive impacts from being in these programs,” said Kristi Lekies, an author on the study and associate professor in the Ohio State University’s School of Environment and Natural Resources.

In some of the cases, the authors of the studies were current or former employees of the therapy programs. Lekies said she thinks the peer review process, in which reviewers study a paper’s methodology, reduces the potential for bias.

A polarizing treatment

Lots of wilderness therapy alums have stories of getting “gooned.”

That’s when transports — typically beefy men — show up at their houses to take them to wilderness therapy, whether they want to or not. It tends to be an unpleasant experience.

Jimi Bailey remembers his mom standing next to the two men in the doorway of their Cleveland home, urging her son to go with them. They took him to RedCliff Ascent in a remote part of Utah, where he was welcomed with a strip search.

This was back in 2007. Bailey said he had fallen in with a gang and gotten hooked on drugs. He spent his first five days there in a canvas tent that acted as a detox station. He said he’d pretend to pass out in hopes of getting sent to the hospital.

After that, every day involved hiking while carrying all his food and gear, even trudging through snowstorms. Bailey said he and many others got diarrhea from their diets, which consisted mostly of rice, oatmeal, bouillon, and a block of cheese once a month. A rare shower was provided via a coffee tin of water heated over the fire. Bailey said he never felt the staff were well trained for the dangerous situations they’d put kids in. He didn’t find his therapist helpful.

When he returned to Cleveland 100 days later, Bailey said he quickly fell into his old ways. Eventually, he cleaned up his act, but he doesn’t credit that to wilderness therapy. He’s now 32 and works as a special education teacher.

“Don’t get me wrong, there are things I take from the program today that are useful,” Bailey said, “But the negative always outweighs the positive in a situation like that.”

In a written response, RedCliff Ascent said it follows best practices from the Joint Commission, one of its accrediting bodies. That includes a “safety check” at intake where items that would make the treatment setting unsafe are confiscated. The program said participants have access to over 3,000 calories per day and they meet with nurses weekly to ensure there’s no concerning weight changes.

Even today, many years after the deaths and Hilton’s stint, people still report mixed different experiences with wilderness therapy. In interviews and online reviews, alumni credit the programs with either turning their lives around or saddling them with lasting trauma, with few in the middle.

“It’s essentially a form of shock therapy,” said Lewis, the Florida attorney. He sent two of his daughters to wilderness therapy when their daily lives involved so much risk, he wasn’t sure they’d survive. He knew being outdoors isn’t risk-free, but he had run out of alternatives.

Several people in the industry said they’re trying to develop a less traumatic intake process. Steve DeBois, clinical director with Second Nature, a wilderness therapy program in Utah, agreed intake can be jarring, but said there aren’t many options when it comes to treatment resistant clients who might otherwise run or harm themselves.

Owen Bogler’s parents sent him to Open Sky, whose expeditions take place in both Colorado and Utah, when he was 16. Now 20, he said the experience of getting gooned was “pretty unpleasant,” but he didn’t see it as a huge deal. That said, he knows others who have awful memories.

Sixteen is a tough age for anyone, but for Bogler, his depression and social anxiety had gotten so bad, he didn’t want to live. He skipped classes, got expelled, refused to leave the house.

His wilderness therapy program meant three months of sleeping outdoors, daily hikes, regular therapy, and “astronaut food.” It was hard, Bogler said. He lost weight. And yet, he thinks it saved his life.

“There’s no time for social anxiety,” he said. “You’re there to work with the team and survive. It basically just taught me how to be by myself and love myself.”

Today, Bogler says he’s doing well. He’s lives in Houston and works in an audio studio after earning an associate degree in audio engineering.

He’s heard the horror stories about other camps, but he feels grateful for his experience at Open Sky. Part of what made it valuable was having a therapist who challenged his thought processes.

“He’s just very straight up, brutally honest even if you don’t want to hear it,” he said. “A lot of therapists I know didn’t do that.”