Recreational Therapists and the Duty of Care

Research Questions

The research reported here was designed to facilitate enhanced understanding of the characteristics and needs of recreational therapists who work with high-promise youth related to personal growth, the context of their work as experiential education and therapy outdoors, their choice to work with high-promise youth, and their experiences of compassion satisfaction and compassion fatigue. The following research questions guided the study:

How do adventure-based recreation therapists understand their work in the context of:

Their experiences

Literature Review

The roots of recreational therapy and adventure therapy are in experiential education, which overlaps with environmental education (Norton et al., 2014). The experiences pursued in adventure-based therapy programs utilize concepts and techniques familiar to environmental educators but with different aims. Rather than explicit calls to environmental action or ecological stewardship, the goals are personal development, healing, and psychological growth, with the recognition that human-nature interactions have evidentiary bases for promoting mental and physical health (Kudryavtsev et al., 2012). As highlighted by the comprehensive work by Gass et al. (2012), adventure therapy requires that there be an active, physical activity facilitated by an educator or rehabilitative professional as a collaborative group effort with an educational component that takes place outdoors. While previous evaluations of such programs that report quantitative findings on youth participant program outcomes are widely available in the literature, what is missing is an exploration of the experiences of the professionals who undergird these programs and oversee the reentry of the youth in their care back into society (Lan et al., 2004; Sampson & Gifford, 2010; White et al., 2018; Wilson & Lipsey, 2000).

Caring professions are those professions which involve a physical or emotional duty of care, or the responsibility to create physical and psychological safety in the service of another person as the primary job function, and include professions such as mental health practitioners, nurses, and educators. A concern for adventure therapists, particularly those who work with high-promise youth, is staff burnout (Bunce, 1998; Ducharme et al., 2007; Marchand et al., 2009; Wozencroft et al., 2019). These professionals are in a position of trust with a duty of care for vulnerable populations of youth in residential settings, in addition to performing the emotionally taxing work of countering maladaptive responses or handling incidents of verbal or physical assault (Wozencroft et al., 2019).

As reported by Bunce (1998), there is high turnover in adventure therapy staff. Turnover numbers may be artificially inflated by programs that are seasonally specific or time-limited, and information is needed on whether those who separate from such employment continue to work in caring professions, as burnout is associated with adverse physical and mental health outcomes (Ducharme et al., 2007). Ducharme et al. (2007) also reported the impact of a coworker social support system as a protective mechanism against burnout and burnout-associated turnover in caring professions. They found significant relationships between workplace attributes and exhaustion, including coworker support being positively associated with reduced exhaustion (Ducharme et al., 2007). This research uses and expands established frameworks for understanding practitioner and client experiences to better articulate personal and workplace attributes which may contribute to or protect against burnout in caring professions.

Schoel et al. (1988) employ a wave analogy to represent the journey of a client of therapy, which follows from a beginning point to a therapeutic goal or change position (Figure 1). Alvarez and Stauffer (2001) used this frame to consider the movement of clients from issues stemming from prior experiences to a desired goal, with examination of current positionalities grounded in the climax, or change point, of the wave of experience. This model is used to describe the importance of the individual client experience within an environmental context. This context includes the natural space, the group or individual setting, the relationship with the professional, and the life experiences of the client. The wave is then analogous to effectively provided opportunities to create new life experiences with altered behavioral responses in the most individually meaningful way for the client (Alvarez & Stauffer, 2001).

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Figure 1.

The wave framework, adapted from text in Schoel et al. (1988).

In the context of this study, the Islands of Healing wave framework (Schoel et al., 1988) is applied to the practitioner rather than the client, with similar expectations for the importance of the environment, the relationships with the client, and personal response patterns important in their personal and professional growth. The researchers posit that the wave may additionally represent the experience of a practitioner who must be attentive to the individual needs of a client in the context of their lived experiences and therapeutic goals, especially when environmental contexts are considered as potentially triggering or alleviating certain behavioral responses. The practitioner must be as engaged in the therapy process as the client by building rapport with their client, understanding the mechanisms that underlie behavioral response patterns, and immediately attending to these responses as they conduct their therapeutic activities with the high-promise youth in their care. The therapist's goal is to guide the client's development through activities aligned with the environmental context, behavioral context, and therapeutic goals while remaining in control of their own responses to best serve the client. The therapist practitioner also has a set of behavioral responses to environmental conditions pursuant to their life experience, and the wave framework can be both personally and professionally relevant to the way they experience their work as adventure therapists for their clients, their colleagues, and themselves as they process and reflect on their work. The wave framework has not previously been studied with practitioners and addresses a gap in understanding how recreational therapists experience their work.

Stamm's (2009) Compassion Satisfaction/Compassion Fatigue (CS/CF) theoretical model (Figure 2) was designed to provide explanatory power between environments and professional quality of life. In most studies, measurement is through the Professional Quality of Life (ProQOL) (Stamm, 2009), a quantitative metric of overall CS/CF in caring professions. CS and CF can come from the same relational area, such as working relationships with colleagues inside and outside of their specific duties—attributes that may be positive or negative depending on the people involved, the structures available to them, or prior experience, among other things (Stamm, 2009). In the CS/CF model, there are no subscales for CS and two subscales for CF, including burnout and trauma. Trauma may be primary (experienced by the individual) or secondary (exposed to the individual through the primary trauma holder). This reflects the intention of the measure to screen for stress-related problems in professionals with a helping or caring position, particularly those who may be exposed to trauma vicariously.

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Figure 2.

The CS/CF theoretical model as described in Stamm (2009).

In the research reported here, the CS/CF and ProQOL models informed the interview questions to elucidate how the recreational therapists experienced their work. For example, recreational therapists in this study may have experienced CS, as described by personality traits such as optimism and altruism, as well as from the emotional rewards from helping others. Alternatively, they may have experienced CF due to personal responses that are triggered by their own traumas or, secondarily, exposure to the traumas of their clientele, in addition to burnout from continued expressions of empathy. They may also have experienced CS/CF in the context of their outdoor work environment, clientele, and ability to experience peer support (or a lack thereof) as indicated by Ducharme et al. (2007). The interview guide was developed for this research to translate a quantitative metric into a qualitative data gathering tool as no qualitative research has been reported in the literature that investigates CS/CF in this population.

Participants

Purposive sampling was employed to gather experiences from those who are uniquely qualified to give them—recreational therapists who work with high-promise youth. Participants were required to have at least 2 years of experience and be between the ages of 18 and 65. These findings are specific to the population studied and should not be generalized to other populations; however, the findings may resonate in other cases.

Design, Materials, and Procedures

Five interviews were conducted with five National Council for Therapeutic Recreation Certification (NCTRC)-certified recreational therapists to reveal their individual experiences and history with the population they worked with, their motivations for joining this profession and for working with this population, and their interactions with youth in a recreational therapy setting. All participants worked for the same rehabilitation center. Interviews were conducted in person, lasted approximately 1 hour, were audio-recorded, and transcribed verbatim. Identifiable information in the transcriptions was disidentified, and pseudonyms were used for privacy. Participants were given the opportunity to member-check the transcripts and to clarify their meaning (Creswell & Miller, 2000; Gillham, 2000).

Analytic Strategy

Data analysis took the form of qualitative content analysis. Thematic analysis from holistic and line-by-line readings identified themes that occurred and reoccurred within and across interviews, as well as areas of disagreement between individual experiences that served to highlight additional areas for future inquiry (Graneheim et al., 2017). This process was enriched by interrater agreement to bolster reliability. Each interview was independently analyzed by two authors and themes were identified within them. These themes were recorded alongside researcher reflections to identify potential biases and discussed with the interrater. Following the initial content analysis, interviews were compared and broader themes across interviews emerged, with subthemes from individual experiences identified.

Researcher Subjectivity

As the lead author, I am not a therapist, nor have I practiced as a professional in any counseling capacity. Rather, my experiences reflect interactions with professionals in my youth. My responsibility as a researcher was to disengage my own experiences from those of the therapists that were reflected in the interviews and to frequently revisit and critically examine my responses to the data, managed in part through researcher reflexivity. Epoché, as described by van Manen (2014), is an intentional thinking style designed to disengage with the natural attitude or our normal, unquestioned experience. I utilized epoché to remove my assumptions and prior experiences. Interrater agreement among coauthors was also a crucial method to ensure validity of findings.

Optimistic Positionality

Participants described inspiration from being surrounded by the progress of others. When asked about the experiences that led to this kind of work, Anya replied “I’ve kind of always had a passion for helping others.” Others echoed their desire to help, saying:

They’re [the youth] my purpose and that's why I’m here is to help them. They wouldn’t be here if they didn’t need it. (Jane)

Ellie described their work as being “accepting and forgiving and willing to extend grace over and over and over to people who kind of make not the right choices over and over and over.”

Participants unfailingly described experiences that began as frustrating or unsafe situations, with problem behaviors from the youth in their therapy groups. Despite these behaviors, none of the therapists attributed these behaviors to negative personality traits, choosing to describe the positive characteristic it revealed, saying:

We have a lot of bossy kids, so I want to teach them how to be a leader and to do that you have to know how to talk to people. So it's okay to be quote unquote bossy but to find a way to do that in a way that is constructive. (Jane)

Anya described a situation where feelings of “fear” and “nervousness” came due to aggressive behavior and immediately countered this description by mentioning that while the client was “very challenging” and “verbally aggressive,” they were a “great kid though. A great personality, a leader in the group.”

Julie described a client that was “defiant, very aggressive” saying “She did not like me at first. I did not like her at first,” continuing to say that the client “did come in, yelling, cussing [. . .] just calling names.” By using her free time for “hanging out with her, just getting to know her,” their bond became the strongest one in memory for Julie, who said “I’ve only cried when two kids have left [the center], and she was one of them.”

They viewed the community as a team, where every member contributed to success, with statements such as:

We all kind of have our part. We all give our feedback, we all play our part in the team. Every decision that's made we make it as a group. (Anya)

Personal Investment

The data illuminated personal investment in the success or failure of therapeutic interventions. Participants expressed disappointment when members of their group were unable to participate and emotional joy from success, saying:

Every day we go through struggles and we go through highs and lows. I have wonderful experiences where I’ve cried tears of joy because of how they just get it, and then sometimes, you just cry because you’re so upset. (Jane)

When discussing how they gained closure when the youth prepare to leave the unit, Anya mentioned that they:

Misrepresentation

The recreational therapists interviewed felt that recreational therapy was largely unknown and sometimes intentionally misunderstood by others. Most frequently cited sources of misrepresentation of their work came from internal colleagues who work on the treatment team but who were not recreational therapists themselves and a general knowledge deficit among friends and family. The following comments indicate this sentiment:

I’m a huge advocate of rec therapy so I like to make sure everyone knows what it is and it's not just PE [Physical Education] or games, ‘cause we have school on campus so a lot of times we get ‘name does PE’ and it's not an insult by any means. (Jane)

Coping with Caring

All of the study participants referenced ways they coped with the challenges of their work. Processing, or the use of recreational therapy tools to deconstruct personal experiences, was something recreational therapists did regularly with their youth but also emerged as an important piece of coping with their work. The therapists said:

The biggest help for me has just been the processing piece of it. Um, you know, we process with our kids, and then we process with each other. (Anya)

Self-care was mentioned in all the interviews, and this facility prioritized self-care among the support staff, holding monthly meetings on self-care practices. However, each of the five participants described struggling to navigate self-care on an individual level, saying:

When asked how they came to understand the importance of such practices, Julie mentioned help from coworkers:

I don’t know, consulting with coworkers, with Mark, about how to like, how to separate that. How do you not take it home? […] Because it took a point of me being physically and emotionally drained that I cannot go to work today, I cannot give anything else.

Personal Growth

The interviews revealed that rewarding aspects of the job lie in observing change in the youth and in recognizing personal growth within the recreational therapists themselves. The therapists shared how they recognized areas for improvement through interactions on the job, saying:

She had got me to the point, where I learned so much about myself, to the point where I was totally out of my character. She had me arguing back and forth. She cursed at me and I cursed back at her – one day, that one day! – and I took a step back and I was like, this is the environment that I work in. I have to figure out how to handle it. [. . .] And she was one that I saw grow and change. I was super excited for her to leave, but also kind of, relieved, like okay. But it was cool to see her growth and my growth, and I would say everybody else around her growth. (Julie)

The Wave of Experience for Recreational Therapists

The five recreational therapists who participated in this study described being confronted with their own mental health needs when they found themselves behaving in ways that they felt were out of character or through recognizing a trigger while working with or decompressing from working with the youth in their care. The experience of recreational therapy for recreational therapists revealed how they cope with the challenges of the work and their chosen population, and each recognized the emotionally taxing nature of the duty of care. All five discussed “processing” with their peers or the use of recreational therapy techniques to work through reactions on difficult days. They often noted that due to the lack of understanding outside of their profession, the support of other recreational therapists was a core part of their effectiveness. These results support the challenges associated with working in caring professions and burnout as described by Ducharme et al. (2007).

The results indicated that the lived experiences of the recreational therapists are brought into the learning and therapeutic context with the youth they work with and that the recreational therapists travel through a similar wave to reach personal growth milestones in a way that provides them with a deep sense of reward from their work. From this understanding, they are able to push themselves to interact with their triggers in productive ways and to reach out for needed support systems until they reach point B, personal growth through changed responses, seen compared to the original in Figure 3. This revised wave framework model provides a way to frame the mutually transformative process of working in outdoor, experiential learning environments with all audiences who may elicit responses that are surprising.

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Figure 3.

The wave of experience for recreational therapists (black), compared to original (blue).

Compassion Satisfaction/Compassion Fatigue in Recreational Therapists

Fundamental definitions of CS and CF as described by Stamm (2009) describe CS as the aspects of caring that generate positive outlooks and intention to remain in the profession and CF as the negative parts stemming from the duty of care that can lead to poor personal and professional outcomes for caring professionals. Stamm's (2009) CS/CF model, a quantitative metric designed to provide insight into the duty of care in professions that require extended expressions of empathy, does not have subscales for CS. The CS scale does use constructs for altruistic rewards and positive interactions in care provision but does not explicitly scale mechanisms by which CS is supported. The scale also does not explicate ways that CS interacts with CF. The model utilizes two subscales for CF, burnout and trauma. We use this framework to explore the way recreational therapists who work with high-promise youth experience the work of caring.

Trauma as an indicator of CF was supported in this study. Participants discussed primary and secondary traumatic exposures in reference to the reasons they chose to move into the profession as well as one of the difficulties with continuing to perform caring professionally. Secondary traumas which impact the person exposed to the trauma through retelling or through other secondhand means of exposure are known as vicarious traumatization. Vicarious traumatization (Bride et al., 2007; Killian, 2008) was not seen in this population, though participants indicate exposure to secondary traumas. The lack of evidence for vicarious traumatization may be due to the therapists’ recognition of their own personal growth through their exposure to these secondary situations and personal triggers. A relationship between vicarious trauma and growth was found by Brockhouse et al. (2011).

The optimism of the recreational therapists connects to their team orientation, contributing to and supporting CS. This holistic outlook on the team effort of rehabilitation feeds back into CS by diffusing responsibility in the work environment, as they view their community as inclusive of the youth and other professionals in a collaboratively responsible way. This mechanism is consistent with Stamm's (2009) model overall, as CS is measured as the positive aspects of caring professions and references an underlying altruism in those who pursue positions with a duty of care. The proposed model stemming from our findings adds a subscale for CS to emphasize the multimodal nature by which CS is achieved and maintained and posits that this positionality is equally as important as self-care and peer support measures to fully capture CS in recreational therapists (Figure 4).

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Figure 4.

Proposed model of CS/CF in recreational therapists.

The recreational therapists discussed using the recreational therapy techniques they employed with their clients on themselves to process through difficult days. Participants cited the need for peer support mechanisms through training for staff on what recreational therapy is, and one member suggested having a recreational therapist on staff to support the staff. Peer support networks have been shown to increase intervention effectiveness in homeless populations from, for example, pairing a homeless individual with a person who has experienced homelessness (Barker & Maguire, 2017) to provide empathy. Peers are experts through experience and can offer genuine companionship and empathy to their networks while holding them accountable for continued growth. In a review, Macran and Shapiro (1998) found that providing therapists for therapists results in increasing empathy and that most therapists report benefits from pursuing therapy. This focus on peer support to combat CF when the work environment is overwhelming indicates that peer support provides an important method to reduce burnout (Figure 4).