The social benefits of nature-based recreation for veterans with posttraumatic stress disorder

Ten to 30% of U.S. military veterans have posttraumatic stress disorder (PTSD) upon their return to civilian life, but many of them face barriers to traditional forms of care. The social stigma associated with receiving clinical mental health services prevents the majority of veterans from receiving assistance through traditional means. Others decline assistance out of a well-intentioned concern that using supportive resources will prevent other people with a greater need from receiving support. Also, researchers have found that the type of trauma a person experiences tends to be less predictive of receiving and recovering from a PTSD diagnosis than the social support, or lack thereof, they receive following the traumatic event. Ultimately, the pervasive nature of PTSD among the veteran community, combined with the barriers to quality care and the critical importance of social support, reinforces the need for nontraditional ways of promoting mental health, reducing PTSD symptoms, and enhancing social support among the veteran community. Therefore, the purpose of this study was to explore the potential social benefits of nature-based recreation for veterans with PTSD. Research results are presented from 1) a scoping review of existing research on the social benefits of nature-based recreation, 2) a qualitative analysis of the social environment that emerges during a river rafting trip for veterans with PTSD, and 3) a quantitative analysis of changes in perceptions of social support over time through participation in a river rafting trip for veterans with PTSD. The findings of this three-article dissertation present new iv information about the social benefits of nature-based recreation and have potential implications for the mental health and wellbeing of the veteran community.

THE SOCIAL BENEFITS OF NATURE-BASED RECREATION FOR VETERANS WITH POSTTRAUMATIC STRESS DISORDER by Deborah Anne Tysor A dissertation submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Parks, Recreation, and Tourism Department of Health, Kinesiology, and Recreation The University of Utah August 2019 Copyright © Deborah Anne Tysor 2019 All Rights Reserved The University of Utah Graduate School STATEMENT OF DISSERTATION APPROVAL The dissertation of Deborah Anne Tysor has been approved by the following supervisory committee members: Kelly Bricker , Chair April 24, 2019 Date Approved Camilla Hodge , Member April 24, 2019 Date Approved Daniel Dustin , Member April 24, 2019 Date Approved Joanna Bettmann Schaefer , Member April 24, 2019 Date Approved Jessie Bennett , Member April 24, 2019 Date Approved and by the Department/College/School of Mark Williams , Chair/Dean of Health, Kinesiology, and Recreation and by David B. Kieda, Dean of The Graduate School. ABSTRACT Ten to 30% of U.S. military veterans have posttraumatic stress disorder (PTSD) upon their return to civilian life, but many of them face barriers to traditional forms of care. The social stigma associated with receiving clinical mental health services prevents the majority of veterans from receiving assistance through traditional means. Others decline assistance out of a well-intentioned concern that using supportive resources will prevent other people with a greater need from receiving support. Also, researchers have found that the type of trauma a person experiences tends to be less predictive of receiving and recovering from a PTSD diagnosis than the social support, or lack thereof, they receive following the traumatic event. Ultimately, the pervasive nature of PTSD among the veteran community, combined with the barriers to quality care and the critical importance of social support, reinforces the need for nontraditional ways of promoting mental health, reducing PTSD symptoms, and enhancing social support among the veteran community. Therefore, the purpose of this study was to explore the potential social benefits of nature-based recreation for veterans with PTSD. Research results are presented from 1) a scoping review of existing research on the social benefits of naturebased recreation, 2) a qualitative analysis of the social environment that emerges during a river rafting trip for veterans with PTSD, and 3) a quantitative analysis of changes in perceptions of social support over time through participation in a river rafting trip for veterans with PTSD. The findings of this three-article dissertation present new information about the social benefits of nature-based recreation and have potential implications for the mental health and wellbeing of the veteran community. iv This dissertation is dedicated to my husband, Anthony Douglas Tysor. Being married to a person who loves my mind is among the greatest gifts of my life. TABLE OF CONTENTS ABSTRACT ....................................................................................................................... iii LIST OF TABLES ........................................................................................................... viii LIST OF FIGURES ........................................................................................................... ix ACKNOWLEDGMENTS .................................................................................................. x Chapters 1 INTRODUCTION ........................................................................................................... 1 1.1 The Nature of Posttraumatic Stress Disorder....................................................... 1 1.2 PTSD and Modern Warfare ................................................................................. 5 1.3 The Social Impact of PTSD ................................................................................. 6 1.4 Problem Statement ............................................................................................... 8 1.5 Theory Guiding the Research ............................................................................ 10 1.5.1 Introduction ............................................................................................ 10 1.5.2 Unpacking the Bioecological Model of Human Development .............. 11 1.5.3 Limitations of Existing Research ........................................................... 17 1.5.4 Conclusion ............................................................................................. 22 2 THE SOCIAL OUTCOMES OF NATURE-BASED RECREATION: A SCOPING REVIEW ........................................................................................................................... 23 2.1 Introduction ........................................................................................................ 23 2.2 Literature Review............................................................................................... 25 2.3 Research Question ............................................................................................. 26 2.4 Methods.............................................................................................................. 26 2.4.1 Eligibility Criteria .................................................................................. 27 2.4.2 Informational Sources ............................................................................ 30 2.4.3 Search Strategy ...................................................................................... 32 2.4.4 Study Records ........................................................................................ 33 2.5 Results and Discussion ...................................................................................... 36 2.6 Conclusion ......................................................................................................... 54 3 THE SOCIAL BENEFITS OF A RIVER RAFTING TRIP FOR VETERANS WITH POSTTRAUMATIC STRESS DISORDER ..................................................................... 57 3.1 Introduction ........................................................................................................ 57 3.2 Research Questions ............................................................................................ 59 3.3 Methods.............................................................................................................. 60 3.3.1 Paradigm ................................................................................................ 60 3.3.2 Researcher as Instrument ....................................................................... 61 3.3.3 Participants ............................................................................................. 63 3.3.4 Research Design..................................................................................... 64 3.3.5 Data Gathering ....................................................................................... 65 3.3.6 Data Analysis ......................................................................................... 71 3.4 Trustworthiness and Ethical Considerations ...................................................... 73 3.5 Results ................................................................................................................ 76 3.5.1 Contrast with Home Life ....................................................................... 76 3.5.2 Activities ................................................................................................ 82 3.5.3 Commonalities ....................................................................................... 84 3.5.4 Group Dynamics .................................................................................... 90 3.5.5 Individual Changes ................................................................................ 93 3.5.6 River Trip Relationship Outcomes ........................................................ 97 3.5.7 Everyday Relationship Outcomes .......................................................... 99 3.5.8 Ideal River Trip .................................................................................... 102 3.6 Discussion ........................................................................................................ 103 3.7 Conclusion ....................................................................................................... 109 4 THE IMPACT OF NATURE-BASED RECREATION ON PERCEPTIONS OF SOCIAL SUPPORT FOR VETERANS WITH POSTTRAUMATIC STRESS DISORDER..................................................................................................................... 111 4.1 Introduction ...................................................................................................... 111 4.2 Research Question ........................................................................................... 113 4.3 Methods............................................................................................................ 113 4.3.1 Setting .................................................................................................. 113 4.3.2 Participants ........................................................................................... 114 4.3.3 Measures .............................................................................................. 116 4.3.4 Data Analysis ....................................................................................... 119 4.4 Results .............................................................................................................. 120 4.5 Discussion ........................................................................................................ 123 4.6 Limitations ....................................................................................................... 124 4.7 Conclusion ....................................................................................................... 125 5 CONCLUSION ............................................................................................................ 127 5.1 Results Through the Lens of the BEM ............................................................ 127 5.2 Final Reflections .............................................................................................. 135 APPENDIX: MET ANCOVA ASSUMPTIONS AND CONTROLLED FOR DEMOGRAPHIC VARIABLES .................................................................................... 143 REFERENCES ............................................................................................................... 145 vii LIST OF TABLES Tables 1.1 Criteria for PTSD diagnosis .......................................................................................... 3 2.1 Databases .................................................................................................................... 31 2.2 Recreation therapy journals ........................................................................................ 31 2.3 Search terms ................................................................................................................ 32 2.4 Coding ......................................................................................................................... 35 2.5 Codes that are presented in the final data report tables .............................................. 36 2.6 Data report table for qualitative studies ...................................................................... 38 2.7 Data report table for quantitative studies .................................................................... 42 2.8 Data report table for mixed method studies ................................................................ 45 3.1 Data sources and intervals .......................................................................................... 66 3.2 Interview questions during the river trip ..................................................................... 68 3.3 Posttrip interview questions ........................................................................................ 69 3.4 Log questions .............................................................................................................. 70 3.5 Themes ........................................................................................................................ 77 4.1 Descriptive statistics ................................................................................................. 121 4.2 Analysis of variance for emotional support .............................................................. 122 4.3 Analysis of variance for social isolation ................................................................... 122 4.4 Analysis of variance for social connectedness.......................................................... 123 LIST OF FIGURES Figures 2.1 Conceptualization of nature-based recreation ............................................................. 49 2.2 Eligibility criteria ........................................................................................................ 52 3.1 Social network analysis............................................................................................... 89 ACKNOWLEDGMENTS This research would not have been possible without the generous financial support of the Kendeda Fund. I would like to thank my advisor, Dr. Kelly Bricker, for her encouragement, support, and wisdom throughout this challenging process, as well as her expertise with qualitative research. Also, I extend my thanks to Dr. Daniel Dustin for his thoughtful reflection on big ideas, Dr. Camilla Hodge for her quantitative analysis skills, Dr. Jessie Bennett for sharing her knowledge of Recreational Therapy with the veteran community, and Dr. Joanna Bettmann Schaefer for her precision and skillfulness in evaluating social support outcomes in wilderness therapy research. Most of all, thank you to the veterans and military members who have faithfully served and are currently serving in the U.S. armed forces. CHAPTER 1 INTRODUCTION As many as 30% of veterans will experience posttraumatic stress disorder (PTSD) during their lifetime (National Center for PTSD, 2018), signifying a steady growth in diagnosis among veterans throughout the past decade (Gates, Holowka, Vasterling, Keane, & Marx, 2012). Simultaneously, few veterans receive adequate assistance when attempting to pursue traditional forms of treatment from the Veterans Health Administration, which is their primary source of health services (Seal, Metzler, Gima, Bertenthal, Maguen, & Marmar, 2009). Left untreated or improperly addressed, veterans with PTSD can experience debilitating social isolation, the deterioration of familial relationships, difficulties maintaining employment and, in some cases, engage in suicidal self-injury or experience death by suicide (Hawkins, McGuire, Britt, & Linder, 2015). In fact, since 2002, the United States has lost more service members to suicide than battlefield casualties (Canandaigua VA Medical Center, 2011). 1.1 The Nature of Posttraumatic Stress Disorder According to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PTSD is a specific collection of symptoms resulting from an individual’s exposure to, “death, threatened death, actual or threatened serious injury, or 2 actual or threatened sexual violence” (APA, 2013). The exposure can occur directly through experiencing it oneself or witnessing it in person, as well as indirectly through extensive exposure to aversive details of an event (APA, 2013). Also, the symptoms must be severe and persistent enough to create distress and functional impairment for the individual in important areas of their life, whether that occurs in relationships, employment, or other settings (APA, 2013). To meet criteria for a PTSD diagnosis, an individual must exhibit the specific symptoms listed in Table 1.1, and the symptoms must not result from medication, substance use, or an alternate health-related condition. When a person demonstrates some, but not all, of the listed symptoms, they are often considered to have “subthreshold PTSD.” If the individual meets criteria for diagnosis between 3 days and 1 month following the traumatic event(s), but the symptoms subside after a month, they may meet criteria for Acute Stress Disorder but not PTSD. In addition, if the symptoms do not surface until 6 or more months after the traumatic event(s), it is referred to as “PTSD with delayed expression” (APA, 2013). Trauma researchers and clinicians widely identify PTSD as a reasonable reaction to unreasonable circumstances (van der Kolk, 2014). While individuals who experience the symptoms may feel as though they should have the capacity to control their behavioral and physiological reactions, particularly if they have a stigmatized perception of mental illness or receiving mental health treatment services, such a perception may be considered an unreasonable expectation given the known impact trauma can have. The neurological and physiological activity involved in a PTSD response produces reactions that originate from the human body’s adaptive intent to preserve the health and wellbeing 3 Table 1.1 Criteria for PTSD diagnosis (APA, 2013) Symptom Cluster 1. Intrusion Criteria At least one symptom. 2. Avoidance At least one symptom. 3. Negative alterations in cognition and mood At least two symptoms. 4. Alterations in arousal and reactivity At least two symptoms. Symptoms Recurrent and involuntary memories, nightmares, dissociation (flashbacks), and psychological and physiological distress following exposure to traumatic reminders. Avoiding trauma-related thoughts, feelings, memories, people, places, or activities. Memory loss about the event; negative beliefs about self, others, or the world; blame of self or others; persistent feelings of fear, horror, anger, guilt, or same; feeling alienated from others; diminished interest in significant activities; and constricted affect. Irritable or aggressive behavior, selfdestructive or reckless behavior, hypervigilance, exaggerated startle response, problems in concentration, and sleep disturbance. of the individual; however, it inadvertently causes difficulties that can impair functioning (Shin, Rauch, & Pitman, 2006). During a traumatic event, the limbic system, and particularly the amygdala, becomes highly activated in what is referred to as the fight, flight, or freeze response (Roelofs, 2017). This portion of the brain is a more primitive area that is responsible for detecting danger, seeking pleasure, and avoiding pain (Roelofs, 2017). It helps protect many animals, including humans, from environmental threats through strongly imprinting dangerous experiences on the brain to identify similar threats that may surface in the future that will need to be avoided (Roelofs, 2017). If a person repeatedly experiences dangerous environments, however, the neural networks in the amygdala become robust, automating and shortening the time it takes for the person to generate a fear response to 4 environmental stimuli (Charuvastra & Cloitre, 2009). While useful for survival, a highly activated limbic system can make it difficult to function within a peaceful, nonthreatening environment (Sareen, 2014). Essentially, the brain has learned to scan for dangerous stimuli and can begin to perceive threats where they do not exist (van der Kolk, 2014). Additionally, when the limbic system becomes activated, the prefrontal cortex tends to shut down (Shin et al., 2006). This process makes it difficult, if not impossible, for a person to make logical, rational decisions that require complex thinking (Shin et al., 2006). According to neuroscientists, the prefrontal cortex is the evolutionary component of the brain that allows humans to engage in thoughtful, reflective cognition and higher order decision making (Shin et al., 2006). When people encounter life-threatening events, however, the human brain resorts to its most basic purpose, which is to achieve survival at nearly any cost (Roelofs, 2017). This deactivation of the prefrontal cortex and activation of the limbic system is an automatic process in response to internal and external stimuli, and it is responsible for many of the symptoms of PTSD (Shin et al., 2006). People usually do not consciously choose to demonstrate PTSD symptoms or perceive stimuli as threatening. Their brain makes that decision for them and responds automatically (van der Kolk, 2014). The realization that their brain and body are behaving in a way that is beyond their control can make PTSD tremendously distressing for people (van der Kolk, 2014). It also tends to make it difficult to function typically in everyday environments, which can impact relationships, employment, and an individual’s capacity to focus long enough to accomplish everyday tasks (Herman, 2015; Sareen, 5 2014). Recent research indicates that certain factors can make it more or less likely that an individual will experience PTSD following a traumatic event (APA, 2013). For example, if a person exists in a dangerous, abusive, or chaotic environment during childhood, they are more likely to develop a highly robust and responsive limbic system (van der Kolk, 2014). Later, if they encounter trauma as an adult, their brain is predisposed to heightened reactivity, increasing their odds of experiencing PTSD (Maschi, Baer, Morrissey, & Moreno, 2012). The presence or absence of social support following trauma can also increase or decrease an individual’s likelihood of developing PTSD (Herman, 2015; Maschi et al., 2012). Highly supportive, nonjudgmental responses can soothe the limbic system, allowing the person to openly and honestly process their trauma using their prefrontal cortex and preserving their belief that good people and safe places exist in the world. Condemning or dismissive social reactions, however, can further elevate the limbic system, intensify the neurological impact of the trauma, and reinforce negative beliefs that fuel PTSD. Perceptions of social support during the traumatic event itself can also impact vulnerability to PTSD as indicated by the study finding that, “reports of low personal and unit morale and lower unit cohesion were linked to increased reports of PTSD symptoms” (Tanielian & Jaycox, 2008, p. 87). 1.2 PTSD and Modern Warfare Recent findings indicate a connection exists between the rising number of veterans with PTSD and specific components of modern warfare, as well as modern 6 changes in military practices in the United States. For example, advancements in modern medical technology have altered the survivability of combat and increased the likelihood of redeployment (Tanielian & Jaycox, 2008). Many injuries that resulted in death during previous wars now cause wounds, injuries, and/or illness. With modern medical advancements, service members either quickly recover and return to duty, or experience a medical evacuation, long-term recovery, and/or permanent disability. While fewer veterans die from combat, they now must be redeployed and/or continue with their lives for many years after enduring traumatic, life-threatening events that previously would not have been survivable. The nature of modern warfare, while different based on the setting and circumstances, tends to share certain features that also may contribute to the rising prevalence of PTSD. Tanielian and Jaycox (2008) note that, “some common stressors in the current conflicts have been identified as roadside bombs, IEDs, suicide bombers, the handling of human remains, killing an enemy, seeing fellow soldiers and friends dead or injured, and the helplessness of not being able to stop violent situations” (p. 44). While some of these elements have always existed in warfare, specific components, such as IEDs and suicide bombers, have become particularly common in recent wars (Tanielian & Jaycox, 2008). 1.3 The Social Impact of PTSD Just as social circumstances can influence vulnerability to PTSD, the consequences of PTSD can have a devastating social impact. From difficulties with emotion regulation to activity avoidance, many of the symptoms of PTSD have a direct 7 social impact. This is particularly evident when the trauma is Military Sexual Trauma (MST), considering that sexual violence is the form of trauma that is most likely to result in PTSD (Kimerling, Gima, Smith, Street, & Frayne, 2007), produces a profound loss of meaning, and significantly inhibits an individual’s capacity to trust other people (Herman, 2015). Veterans with PTSD also often face significant challenges in important relationships, especially marriage and family relationships, while navigating trauma recovery (Tanielian & Jaycox, 2008). Studies have shown that veterans with PTSD are more likely to experience various negative effects in intimate relationships, including “compromised parenting, family violence, divorce, sexual problems, aggression, and caregiver burden” (Price & Stevens, 2017). Also, veterans’ relationships with partners and family members may have experienced strain associated with one or more deployments, impairing the quality of important relationships during the trauma recovery process and decreasing family resilience (Tanielian & Jaycox, 2008). On a broader level, PTSD among veterans can have a societal impact through the increased likelihood of experiencing employment issues, resulting not only in difficulties for the individual but a tremendous loss to the labor market. A study by Smith, Schnurr, and Rosenheck (2005) found that “veterans with more severe [PTSD] symptoms were more likely to work part-time or not at all” (p. 89). A study of Vietnam veterans found that veterans with PTSD are more than three times more likely to be unemployed when compared to veterans without PTSD, even when accounting for co-occurring conditions and demographic factors (Zatzick et al., 1997). Unstable employment not only can produce financial difficulties for the veterans but deprives the labor market of the 8 valuable contribution that the veteran may have otherwise, in the absence of trauma, had the potential to provide. Finally, certain cultural factors within the military, such as stigmatized perceptions of using mental health services, can prevent veterans with PTSD from receiving treatment (Tanielian & Jaycox, 2008). Therefore, it is important to address the needs of a growing number of veterans with PTSD and the social challenges they tend to face using nontraditional forms of treatment that carry less stigma but still produce valuable outcomes. 1.4 Problem Statement Having positive perceptions of social support has been strongly associated with a decreased risk of receiving a PTSD diagnosis upon return to civilian life, as well as an overall decrease in symptoms among those who have PTSD (Woodward et al., 2015). Fortunately, a growing body of research suggests that certain nontraditional forms of treatment, especially nature-based interventions, tend to increase perceptions of social support and, subsequently, may improve treatment and recovery for veterans with PTSD. For example, a study of outdoor snow sports programs for veterans with PTSD found the interventions contributed to, “significant decreases in PTSD symptoms and increases in marital satisfaction” (Bennett, Lundberg, Zabriskie, & Eggett, 2014a, p. 74). River-based interventions, such as fly-fishing (Flammang, 2011; Mowatt & Bennett, 2011; Vella, Milligan, & Bennett, 2013) and river-running (Dustin, Bricker, Arave, Wall, & Wendt, 2011; Dustin, Tysor, Bricker, & Brownlee, 2017) have also demonstrated usefulness in building camaraderie, improving relationships, facilitating personal 9 reflection, and reducing symptoms in veterans with PTSD. Gardening, another naturebased intervention, has also demonstrated the potential to assist recovery from disruptive life events through increasing resilience among military community members (Krasny, Pace, Tidball, & Helphand, 2012). Hiking, hunting, and other forms of nature-based recreation have also begun to receive increased attention regarding their potential mental health benefits (Rogers, Loy & Brown-Bochicchio, 2016). Themes emerging from this research suggest that naturebased recreation provides a unique context for cultivating valuable social support among veterans and between veterans and their family members, friends, and the wider community. These social outcomes are linked to improvements in mental health and specifically target the social challenges that PTSD can frequently produce (Bennett et al., 2014a; Rogers et al., 2016). Nature-based recreation interventions not only seem to produce valuable social results but also may have the added benefit of being particularly appealing to people who have negative perceptions of traditional treatments (Rogers et al., 2016), making it a valuable alternative therapy for reaching people who would not otherwise pursue treatment. As previously noted, creating and enhancing positive social relationships is also critical to the trauma treatment and recovery process. Therefore, the consistency with which nature-based interventions produce positive social outcomes offers hope for providing more effective, nontraditional ways of meeting the most crucial needs of veterans with PTSD. Despite promising new developments regarding the demonstrated benefits of nature-based recreation for veterans with PTSD, river running has received minimal 10 attention as a potentially valuable form of recreation (Scherer, Gade, & Yancosek, 2014). Even though the evidence in favor of river trips as a restorative environment is lacking, organizations throughout the nation spend thousands of dollars and countless hours facilitating a variety of river trips for veterans with PTSD in the hope that it has substantial value. Therefore, the following chapters of this dissertation will explore the social benefits of nature-based recreation for veterans with PTSD. More specifically, a scoping review will aggregate and synthesize existing research on the social outcomes of nature-based recreation; a qualitative case study of a river-rafting trip will evaluate the social environment that emerges; and a quantitative study will analyze changes in perceived social support through river rafting. 1.5 Theory Guiding the Research 1.5.1 Introduction The Bioecological Model (BEM) of human development outlines the components of human experience that collectively and interactively contribute to development. The BEM also explains how components of human development influence each other and contribute to study outcomes. Over time, parts of the model have changed and been clarified as new research information has arisen. Researchers have used the BEM to inform study design, provide a rationale for the outcomes they anticipate, and explain research findings. The BEM was used in this dissertation to interpret the social outcomes of naturebased recreation. The BEM was particularly relevant to this research because it accounts for the ongoing interaction between multiple factors that impact social outcomes. It also 11 acknowledges the reality of ongoing developmental processes that occur during adulthood, which is unique among existing human development theories. Most importantly, the BEM provides reasonable explanations for why the social, physical, individual, and temporal factors associated with NBR collectively contributed to social outcomes. 1.5.2 Unpacking the Bioecological Model of Human Development Bronfenbrenner and Morris (2006) define human development as “the phenomenon of continuity and change in the biopsychological characteristics of human beings, both as individuals and groups. The phenomenon extends over the life course, across successive generations, and through historical time, both past and future” (p. 793). Conceptualizing development this way differs from other human development theories in that it recognizes the substantial impact of environmental factors that interact with and contribute to both individual and group development. Other theoretical lenses used to understand and interpret human development tend to emphasize the individual with a narrow and/or unidirectional scope. For example, learning theories, “focus on changes in beliefs and behaviors that are associated with experience” (Newman & Newman, 2016, p. 133), such as how an individual’s perceptions and expectations influence their behavior. Other theories conceptualize human development from a biological perspective, giving, “a strong role to biologically based capacities that guide the direction and nature of growth” (Newman & Newman, 2016, p. 17). The BEM, however, views development as a lifelong process in which biological, psychological, cognitive, internal, external, social, historical, 12 environmental, and other factors that contribute to both individual and group development engage in an interactive process of mutually impactful, constant change. Essentially, the scope of Bronfenbrenner’s conceptualization of human development is much broader than most. Also, development has traditionally been defined as changes that occur in a particular direction throughout an individual’s lifetime. Bronfenbrenner claims that, over time, developmental processes tend to become “progressively more complex” (1994, p. 38). However, he recognizes that development often includes both positive and negative changes that have the potential to become less organized and less integrated. For example, an individual might become more socially isolated or experience cognitive deterioration as they age or if they experience a disruptive life event. Bronfenbrenner introduced the first iteration of the BEM in a 1979 publication of The Ecology of Human Development. The BEM is based on two primary propositions: 1. “Human development takes place through processes of progressively more complex reciprocal interaction between an active, evolving biopsychological human organism and the persons, objects, and symbols in its immediate environment” (Bronfenbrenner, 1994, p. 38). These forms of interaction are referred to as proximal processes. 2. “The form, power, content, and direction of the proximal processes effecting development vary systematically as a joint function of the characteristics of the developing person; of the environment – both immediate and more remote – in which the processes are taking place; and the nature of the developmental outcomes under consideration” (Bronfenbrenner, 1994, p. 38). 13 Early on, Bronfenbrenner did not fully recognize the profound impact that time can have on proximal processes. Eventually, however, he came to acknowledge that, “to be effective, [proximal processes] must occur on a fairly regular basis over extended periods of time” (Bronfenbrenner, 1994, p. 38). Therefore, in its current form, the four key concepts of the BEM include process, person, context, and time: 1. Process: The process concept refers to “any of a wide range of interactions between a person and the environment” (Newman & Newman, 2016, p. 290). Processes tend to involve some form of activity (e.g., reading a book, buying groceries, etc.). Also, the degree to which an individual engages with a process, instead of simply being subject to a process, often changes over time as a person advances in age. For example, babies tend to be passive participants in processes but become more actively involved as they become toddlers, and are usually active agents in processes as adults. 2. Person: the BEM acknowledges the profound impact of an individual’s biopsychological characteristics on the developmental processes. Bronfenbrenner argues that individual differences, “might influence the way the person engaged in a setting, the kinds of resources or opportunities that the setting might provide due to these characteristics, or barriers that the person might encounter” (Newman & Newman, 2016, p. 290). In more recent iterations of the BEM, Bronfenbrenner identifies three types of characteristics that have the most significant influence on human development, as they greatly inform how a person engages with proximal processes: 14 a. Dispositions: these enduring characteristics include “features of a person that can alter the way a person engages a setting” (Newman & Newman, 2016, p. 290). For example, the amount of self-efficacy, determination, and patience an individual demonstrates are all potential dispositions that could impact the way a person interacts with their environment. b. Demand Characteristics: these types of characteristics include elements of a person that are often externally visible to the people around them (e.g., age, skin color, gender, etc.) that impact environmental experiences based on the perceptions and expectations of other members of the environment. c. Resources: these include physical, cognitive, emotional, and social resources that impact the way a person engages with their environment. For example, having a particular knowledge base, access to quality health care, and emotion regulation skills will likely influence the way an individual interacts with the setting around them. 3. Context: this concept refers to the features of the environment where activities and behaviors take place. Contexts are categorized into nested levels, ranging from those most proximate to those most distal to the individual. These levels were not identified when the BEM was first introduced, but were incorporated as more information about the nature of processes became evident through further investigation and research: a. Microsystem: this context level can be generally defined as “a setting with particular physical characteristics and resources… characterized by patterns of activities, roles, and interpersonal relations experienced by the 15 developing person” (Newman & Newman, 2016, p. 291). The microsystem includes overtly evident features of the context, as well as the individual’s perceptions, beliefs, and opinions about the setting. Examples of microsystems could include an individual’s family, recreation environment, workplace, and social group. The BEM carries the assumption that an individual’s microsystem likely becomes more complex, and the number of microsystems a person engages with tends to increase with time. Also, an individual usually has increased freedom to choose which microsystems they would like to participate in as they age. b. Mesosystem: this context level involves the way two or more microsystems interact with and impact one another. For example, a negative interaction at work can impact the way an individual behaves at home. Conversely, useful information gained at school can improve the way an individual engages in their family environment or social group. Essentially, the mesosystem is an individual’s social network. c. Exosystem: this context level, “refers to one or more settings that do not involve the developing person as an active participant, but in which events occur that affect – or are affected by – what happens in the setting containing the developing person” (Newman & Newman, 2016, p. 292). For example, if a parent had an experience at work that changed their behavior at home, and that change impacted their child, the parent’s work environment would be considered one of the child’s exosystems. The child is not an active participant at their parent’s work, but what happened in the 16 work context impacted their home life (one of their microsystems) through their parent’s life. Examples of exosystems may include a person’s neighborhood, their in-laws, and/or their child’s school. Exosystems were not included in the list of context levels until 1995 when they were introduced through a research study by Steinberg, Darling, and Fletcher. d. Macrosystem: the most distal level of an individual’s context, a macrosystem refers to, “the culture of society that frames the structures and relationships among the systems” (Newman & Newman, 2016, p. 293). This could include the laws, policies, economic systems, history, culture, and other overarching forces that frame the values and events that impact an individual’s developmental context. 4. Time: the BEM takes into consideration how “the individual and the systems in which the person is embedded change over time” (Newman & Newman, 2016, p. 293), and that these changes impact development. The BEM is primarily used by family and environmental researchers to examine how certain proximal processes, in conjunction with individual characteristics and specific contexts, impact development over time (Bronfenbrenner, 1994). Most research that uses the BEM focuses on childhood development and the achievement of specific developmental outcomes, which may be a function of the fact that Bronfenbrenner himself was primarily interested in child development. Existing research has shown that, particularly within child development, proximal process, such as the relationship between a parent and child, access to stable financial resources, and social support for the parents themselves impact developmental outcomes for the children (Bronfenbrenner & Morris, 17 2006). However, the need seems to exist for increased application of the BEM in adult development research. Bronfenbrenner also has continually reinforced the importance of theory building and research to co-occur, seeking discovery rather than simply pursuing confirmation or validation of the model as it currently exists (Bronfenbrenner & Morris, 2006). The BEM uniquely acknowledges the importance of the setting in which human development occurs, which makes it difficult to apply it to laboratory-based research or studies conducted in an artificial setting. Instead, most research that utilizes the BEM takes place in an environment comparable to how the phenomena under investigation exist in real-life settings. This makes the BEM ideal for evaluating the outcomes of research that rely heavily on the environmental context, such as nature-based recreation research. 1.5.3 Limitations of Existing Research Unfortunately, many studies that claim to use the BEM neglect proximal processes, which are central to understanding development from a bioecological perspective (Bronfenbrenner & Morris, 2006). Researchers frequently cite Bronfenbrenner, “as a theorist of context” (Tudge, Mokrova, Hatfield, & Karnik, 2009, p. 200), focusing entirely on the environmental components that contribute to outcomes rather than acknowledging all the bioecological contributors of the person to the context and the subsequent developmental outcomes. While nature-based recreation research could run the risk of making a similar mistake, the focus on social outcomes and the use of a mixed-methods approach provides space for the evaluation of multiple factors that 18 interactively and collectively contribute to outcomes. The BEM has been applied in recent years to research in the veteran and military community to investigate and analyze psychological health outcomes (Benda, 2001; Evans, 2016; Kohrt, Jordans, & Tol, 2010; Price, 2015; Ryan, 2016; Scanlon, 2016; Storms, 2014; Vuković et al., 2015; Wooten, 2013), hospitalization rates (Benda, 2001; Price, 2015), family wellbeing (De Filippe, 2016; Dumars, 2013; Lester & Flake, 2013; Storms, 2014; Vuković et al., 2015), caregivers (Novas, 2016), and postdeployment reintegration (Kohrt, Jordans, & Wietse, 2010; Ryan, 2016; Scanlon, 2016; Wooten, 2013). Unfortunately, most of these studies only briefly mention the BEM, largely about the reality that environmental factors, particularly social factors, impact developmental outcomes. Consequently, very few studies address the bio- part of the Bioecological Model or the proximal processes that contribute to development. Within this research study, however, biological factors were taken into consideration when evaluating outcomes. For example, if an individual has a brain injury that influences their social interactions, the qualitative data collection process intentionally provided space for this information to be discussed by participants through interviews, journaling, and observations made during group interactions. Much of the research that claims to be informed by the BEM also fails to identify how all four key concepts (process, person, context, and time) are present in the research. According to Tudge et al. (2009), “if a research design, for whatever reason, does not permit adequate assessment of one or more of the elements, this fact should be clearly acknowledged in order to preserve the integrity of the theory” (p. 200). Selectively noting the relevance of only one or two components is acceptable only if the researchers 19 acknowledge that they are doing so. Failing to identify one’s selectivity threatens to perpetuate misunderstanding and the continued misuse of the BEM. Within this dissertation, all four concepts were addressed in various ways. For example, the interaction between three specific contextual levels from the BEM was particularly unique to the river trip setting and was expected to have a major impact on the social environment and outcomes of the trip. It was expected that an all-veteran excursion would be a cultural factor that would dramatically influence the microsystem and the proximal processes occurring within it. Individual perceptions, experiences, and biophysical characteristics were also likely to impact how the participants engage with the veteran culture and, subsequently, have a developmental influence on the participants. Other factors, such as gender, education level, race/ethnicity, age, service experience, and trauma type, were expected to impact the veteran dynamic. For example, if the group was predominantly male and the only female veteran on the trip endured MST, being outnumbered and having experienced trauma at the hands of a fellow veteran might have impacted the way the female group member interacted with her fellow participants, as well as the way they perceived and interacted with her. Similarly, if only one veteran experienced combat, which is a highly unique and often deeply impactful context, they may have seen the lack of shared combat experience with fellow participants as a barrier to engaging freely and comfortably in the group. Conversely, the element of time, through spending multiple days together, may have helped the participants begin to break down perceived social barriers that otherwise may have existed due to their personal characteristics and the characteristics of the other people in the group. These factors were accounted for in the qualitative analysis of the 20 social environment through questions presented in the interviews and written logs. Also, Bronfenbrenner and Morris (2006) claim that all studies utilizing the BEM should be longitudinal. Therefore, time was accounted for in the quantitative analysis of the social environment that emerged during the river trip using a longitudinal approach. The scoping review accounted for the potential developmental influence of time by coding for the length and study design of each trip. Another contextual factor that may have influenced the social dynamic was the fact that all participants were required to have a current PTSD diagnosis. Existing in a microsystem where everyone experienced similar symptoms that were caused by a particular trauma or set of traumatic encounters was unique. Given that only approximately 7% of the general population tends to meet diagnostic criteria for PTSD (National Institute of Mental Health, 2017), it was unlikely that most of the participants were surrounded by a group of people suffering from the same condition as they were in their daily life. Ideally, spending time with fellow veterans who also have PTSD would increase shared understanding and improve the value of the social dynamic for all participants. The possibility existed, however, for individual differences in participant experiences of PTSD to create social barriers as well. For example, if an individual had severe and persistent PTSD symptoms that tended to be particularly disruptive to establishing and developing social relationships, such as extremely negative beliefs about themselves or others, this may have prevented such individuals from engaging meaningfully in the social context. According to the BEM, this barrier could mutually impact the social experience of other participants, having an interactive effect on the 21 social environment and developmental outcomes of the trip, not just at the individual level, but at the group level as well. A final contextual component that is particularly unique and may impact human development is the physical environment. With increased urbanization, people decreasingly engage with nature-based environments (United Nations Population Division, 2015), which makes it likely that the river-based physical context is highly removed and distinct from the everyday lives of the participants, providing a novel experience. Both person characteristics are likely to interactively influence and be influenced by the physical context through ongoing proximal processes that impact social outcomes. For example, if a person was new to nature-based recreation and spent most of the trip adjusting to it, their experience was likely to be quite different from the individual who had engaged in multiple river trips and felt at ease in that setting. Also, individual differences, such as one’s comfort level with engaging in new experiences or willingness to help other people feel more comfortable, was likely to impact how participants behaved and interact with those around them within the nature-based setting. Personal characteristics might change as a consequence of interactions with the natural environment, including resource characteristics relating to knowledge and skills that are useful for participating in NBR. The natural physical setting also involves repeatedly encountering physical challenges that can impact the social outcomes of the trip. Again, personal characteristics and the proximal processes of these factors interacting with each other will influence the outcomes as well. An individual’s sense of self-efficacy, their physical abilities, any disabling condition(s) they may have, and their level of desire to engage in the physically 22 challenging environment might interplay with the social dynamic, impacting outcomes for all of the participants. For example, if a person struggles to navigate the process of getting into and out of the boat every day, someone else who feels differently about their physical capacity and/or has different physical abilities might step in and help the other person navigate that challenge. The nature of these exchanges was likely to impact the overall social dynamic and the development of both the group and the individuals throughout the river trip. The physically challenging nature of the nature-based context, therefore, would likely have had a direct impact on the nature and outcomes of the trip. Both the challenge and nature-based components of the physical environment were accounted for through the qualitative data gathering process of asking specific questions in the interviews and journals, as well as through observations of participant behaviors. 1.5.4 Conclusion Overall, the Bioecological Model of human development contains key concepts and propositions that have evolved over time and, in their current form, have a unique capacity to inform and explain the social outcomes of nature-based recreation for Veterans with PTSD. The BEM has qualities that are particularly suited to the analysis of this particular phenomenon. It was expected that the process, people, context, and timerelated components of the studies were all likely to contribute to social outcomes through their complex, ongoing interaction and have a subsequent developmental impact at both the individual and group level. CHAPTER 2 THE SOCIAL OUTCOMES OF NATURE-BASED RECREATION: A SCOPING REVIEW 2.1 Introduction United States veterans returning from military service often encounter a variety of cognitive, psychological, and social challenges while reintegrating into civilian life. Regarded as the signature injury of modern warfare, mild traumatic brain injury (mTBI) has become pervasive throughout the veteran community in recent years, particularly among those returning from combat deployment (Snell & Halter, 2010). When it comes to psychological injuries, some studies find that 15% of service members meet the criteria for a posttraumatic stress disorder (PTSD) diagnosis (Tanielian & Jaycox, 2008), while others argue that rates from certain service experiences, such as combat deployment during the Vietnam war, more closely approximate 30% (National Center for PTSD, 2018). Both mTBI and PTSD can have a damaging influence on a veteran’s social experiences, from higher divorce rates and greater marital difficulties (Tanielian & Jaycox, 2008), to feelings of isolation and increased interpersonal conflict (van der Kolk, 2014). Furthermore, negative social experiences, such as stigma related to receiving mental health services (Tanielian & Jaycox, 2008) and judgmental or condemning 24 responses when an individual discloses details related to personal experiences of trauma (Herman, 2015), can both exacerbate symptoms and create barriers to seeking traditional forms of treatment. In recent years, increased attention has been given to the potential benefits of nontraditional, complementary health practices that may demonstrate value in addressing the cognitive, psychological, and social needs of some veterans. More specifically, researchers have increasingly investigated the potential health benefits of nature-based recreation (NBR) experiences (Keniger, Gaston, Irvine, & Fuller, 2013). Various naturebased activities have been evaluated for their potential to promote health (Richardson & Mitchel, 2010), improve cognition (Atchley, Strayer, & Atchley, 2012), and enhance psychological wellbeing for diverse populations (Bielinis, Takayama, Boiko, Omelan, & Bielinis, 2018). Findings indicate that NBR has the potential to produce valuable, wideranging benefits for many people, from young people (Gustafsson, Szczepanski, Nelson, & Gustafsson, 2011) to older adults (Boyes, 2013). Meanwhile, the impact of strong social networks, positive perceptions of social support, and social cohesion on health, wellbeing, and even mortality have been repeatedly confirmed (Cacioppo, Cacioppo, & Boomsma, 2014; Christakis & Fowler, 2011; Shinew, Glover, & Parry, 2004). Nature-based recreation interventions not only seem to produce valuable social results, but also may have the added benefit of being particularly appealing to people who have negative perceptions of traditional treatments (Rogers, Loy, & Brown-Bochicchio, 2016), making it a valuable alternative therapy for reaching people who would not otherwise pursue treatment. Despite NBR experiences demonstrating usefulness in addressing social needs (Boyes, 2013), researchers have yet 25 to conduct a literature review that specifically focuses on the present state of knowledge and the characteristics of the literature regarding the social benefits of NBR. 2.2 Literature Review According to Booth, Sutton, and Papaioannou (2016), there are three primary types of literature reviews that differ according to their scope, which the researchers identify when they clarify the purpose of the review. A scoping review most frequently occurs when researchers are evaluating an emerging concept that has not yet received extensive attention. The purpose of a scoping review is, “to find out how much literature exists [and] to find out the characteristics of the literature” (Booth et al., 2016, p. 98). For example, a scoping review may look at the types of methods used, the age of the samples, the application of theory, and/or the setting in which the research took place (Gillespie, Kelly, Duggan, & Dornan, 2017). In a mapping review, the researcher “aims to identify gaps in the literature in order to commission further research” (Booth et al., 2016, p. 98). This type of review specifically seeks to evaluate what types of work have been done in a specific area and what information is still lacking in the body of research. Another type of literature review, called a systematic review, “aims to be comprehensive… tends to focus on the highest quality evidence available… [and the] scope should be well-defined and clearly stated” (Booth et al., 2016, p. 98). Systematic reviews tend to cross disciplinary boundaries, incorporate international publications, include many languages, and incorporate a wide range of source materials (e.g., published articles, technical reports, dissertations, and theses, etc.). During the coding 26 process, systematic reviews tend to focus on key relationships and themes that are present in the literature, include studies with results that contradict each other, and extend the generalizability of findings (Booth et al., 2016). As previously stated, the investigation into the measurable outcomes of various forms of NBR is a small but growing field of research. Furthermore, attention has recently been drawn to the potential social benefits of NBR, and researchers have yet to conduct a literature review in this topic area. Therefore, the purpose of this analysis was to conduct a scoping review that evaluates the current state of research regarding the social outcomes of NBR experiences. In alignment with the purpose of a scoping review, this analysis focuses on identifying the characteristics of existing literature and exploring the breadth and depth of research on NBR and social outcomes. 2.3 Research Question 1. According to existing published research, what are the social outcomes of participating in nature-based recreation? a. What are the characteristics of the literature? 2.4 Methods To ensure the highest quality and systemization of analysis, this scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015) reporting guidelines (Moher et al., 2015). These guidelines provide a 17-item checklist establishing international standards for how literature reviews ought to be conducted to enhance standardization in review 27 processes. The following methods align with the reporting guidelines established by PRISMA-P 2015. 2.4.1 Eligibility Criteria Per the PRISMA-P reporting guidelines, eligibility criteria for inclusion and exclusion were established before conducting the review. Standards regarding the conceptualization and operationalization of social outcomes and nature-based recreation, as well as the measures used, methodology, sample, and peer review process aligned with the following requirements. 2.4.1.1 Social Outcomes For this study, a social outcome refers to any positive changes in human interaction at the individual, group, community, and systemic levels. This includes personal perceptions because the way an individual perceives a social component of their life has been strongly associated with factors relating to health and wellbeing, regardless of the objective state of their social circumstances (Gülaçt, 2010). Social benefits can also be present at the community or societal level, such as reductions in crime (Kuo & Sullivan, 2001). To gain a comprehensive understanding of the potential social outcomes of NBR, social benefits at whatever level those benefits may exist, from individual to systemic, were included in this review. 28 2.4.1.2 Nature-Based Recreation To be included, the social outcomes must relate to or result from direct, measurable experiences of NBR, which is defined as, “all forms of leisure that rely on the natural environment” (Jenkins & Pigram, 2003, p. 328). This can include anything from gardening to climbing a mountain. However, some forms of recreation, such as swimming, cycling, and challenge course activities, can occur in both nature-based and artificial settings. Therefore, studies were only included in this review if the researcher(s) specified that the recreation relied on the natural environment. Also, if the NBR experience is combined with a potentially important component that is not controlled for, such as clinical therapy or formal competition, it was still included in the analysis, but a note was made regarding the potential impact of confounding variables. To ensure study outcomes related to real-life engagement in NBR and not exposure to artificial replications of nature, studies where NBR experiences were operationalized as exposure to pictures of nature were not included. Furthermore, researchers have found that reflecting on past experiences can involve a memory bias since people change the way they interpret their experiences over time, which can modify the impact of those experiences (Patterson & Mattila, 2008). Still, some studies evaluate the impact of recollections of past outdoor recreation experiences, in which the effect of nostalgia is not adequately separated from the impact of the recreation experiences themselves (Glassman, 1995). Consequently, studies that operationalized NBR by asking participants to think about an outdoor experience from their past or reflect on recreation that occurred more than 1 month prior to data collection were eliminated from this review, unless the delayed data collection was part of a longitudinal design where data 29 were also collected at intervals more proximate to the NBR experience. 2.4.1.3 Measures If a study used multiple measures and not all of them evaluated social outcomes, it was included if the researchers reported the results of each measure separately. Any additional measures used in the study that did not report social outcomes were not coded in this review. Similarly, if the researcher(s) used a measure that had subscales and one or more of the subscales evaluated social outcomes, the study was only included if the researcher(s) separated the different components of the measure(s) and independently reported the social outcome(s). 2.4.1.4 Methodology Both quantitative and qualitative studies were included to allow for a comprehensive evaluation of the characteristics of the literature. 2.4.1.5 Sample Since the rationale for this scoping review is founded upon an interest in social outcomes that can be cultivated among the veteran population, and U.S. military enlistment without parental consent has an 18-year-old minimum age (Smith, 2019), articles that included people under the age of 18 in their sample were excluded. 30 2.4.1.6 Refereed Studies Only published articles from refereed journals were included. While this approach ran the risk of excluding potentially relevant material, it provided an additional level of assurance in the quality of methods and design within the studies that were incorporated, which has been established as a standard procedure when conducting a scoping review (Zajchowski, Brownlee, & Rose, 2018). Consequently, secondary literature, such as dissertations, theses, technical reports, and book chapters were excluded from this review. 2.4.2 Informational Sources To ensure the selection and evaluation of a comprehensive, thorough list of relevant articles, the first step in the process involved searching the databases listed in Table 2.1. Databases were selected based on their relevance to the research question, as well as their capacity to comprehensively contain peer-reviewed literature. Through repeated consultation with two librarians at the University of Utah, conducting multiple practice searches, and confirmation with a diverse team of researchers who are professionally experienced in the topic of this review, the databases in Table 2.1 were identified as demonstrating the capacity to comprehensively contain material relevant to the research question. Within a scoping review, consideration must also be given to “recent publications within journals known to have a significant publication record in this area of research” (Bell, Foley, Houghton, Maddrell, & Williams, 2018, p. 124). Recreational therapy (RT) has long established itself as a field of study that provides activity-based therapeutic 31 Table 2.1 Databases Database PsycINFO Description “A world-class resource for abstracts and citations of behavioral and social science research” (American Psychological Association, 2019). CAB Abstracts “The leading English-language bibliographic information service providing access to the world’s applied life science literature” (CABI, 2019). Scopus “The largest abstract and citation database of peer-reviewed literature” (Elsevier, 2019). Sociological Abstracts “Cover(s) the international literature of sociology, social work, and related disciplines in the social and behavioral sciences” (ProQuest, 2019) interventions for people with a range of illnesses, injuries, and disabling conditions (American Therapeutic Recreation Association, 2019a), which includes NBR interventions. To include recent publications from the field of RT that the preceding databases do not include, online archives of publications from the RT journals listed in Table 2.2 were manually reviewed for potentially relevant studies. Also, to allow for Table 2.2 Recreation therapy journals Journal American Journal of Recreation Therapy (AJRT) Description “The unchallenged journal of record in the field and the gold standard for providing recreational therapists the latest research, techniques, and advances in the use of recreational intervention” (AJRT, 2019). Therapeutic “The journal, published for over 50 years, provides a national Recreation Journal forum for research and discussion on the needs of persons (TRJ) with disabilities, problems confronting the profession, new vistas of service, and receiving therapeutic recreation services” (Sagamore Publishing, 2019). Annual in Therapeutic “The purpose of the Annual is to further advance the body of Recreation (ATRA knowledge of the therapeutic recreation profession by creating Annual) new knowledge and understanding in practice and in education” (American Therapeutic Recreation Association, 2019b). 32 replication of this review and account for potential differences in future searchers, the exact date and time that the search was conducted in each database and recreational therapy journal are reported. 2.4.3 Search Strategy In 1984, Ulrich published a study evaluating the influence of exposure to a natural setting through a hospital window when recovering from surgery. His publication is considered a seminal work that initiated the ongoing exploration of the potential benefits humans receive from exposure to nature-based settings. Consequently, only studies published from 1984 onward were included in this scoping review. Also, as previously mentioned, only articles published in English from refereed journals were included. If a database demonstrated the capacity to exclude publications in non-English languages and secondary literature, such as dissertations and theses, from the initial search results, that option was employed in the initial search process. Table 2.3 lists the terms that were used to generate a comprehensive list of articles related to each of the primary concepts of interest. These search terms were initially Table 2.3 Search terms Concept Nature-Based Recreation Social Outcomes Search Terms “nature-based” OR “outdoor recreat*” OR “forest bath*” OR “wilderness” OR “greenspace” OR “ecother*” OR “adventure” (AND) “social*” OR “group*” OR “communit*” OR “systemat*” (AND) “outcom*” OR “percept*” OR “support*” OR “belong*” OR “treatment*” OR “cohes*” OR “cooperat*” OR “interaction*” OR “value*” OR “connect*” OR “learning” 33 identified through repeated consultation with two librarians at the University of Utah and confirmed through practice searches and a review of the keywords and terms frequently used in articles from multiple disciplines that align with the topic of interest. The terms were also approved by a team of researchers with extensive professional experience related to the research question. 2.4.4 Study Records 2.4.4.1 Data Management Throughout the review process, the citations and articles were organized, stored, and evaluated using Covidence, an online program created by Cochrane (2019) that facilitates the literature review process (Covidence, 2019). It allows all of the citations and full texts to be stored in a single location and accessed by multiple researchers who are involved in the review. Additionally, it maintains a record of why the researchers agreed on eliminating each article and, if applicable, how differing perspectives were resolved. Covidence was selected as the primary data management tool to streamline the overall review process, ensure consistency throughout the article selection process, and enhance data management quality. The final list of articles and codes were exported and stored in an Excel (2018) document. 2.4.4.2 Selection Process Once all relevant citations and corresponding abstracts were generated through the database searches, the primary researcher imported the citations and abstracts into Covidence (2019). The first stage of the selection process involved a single researcher 34 reading through the citations to identify and remove any duplicate articles. Once all of the duplicates were removed, two researchers independently read the title and the abstract of each article to identify whether or not a study met the inclusion criteria and exclude irrelevant studies. If the title and article did not collectively provide enough information to identify whether or not the study met eligibility criteria for this review, or if the researchers disagreed about whether or not to eliminate an article at this stage of the process, it was not removed until the full article was reviewed. Next, the full texts of all of the articles that remained were downloaded and, if necessary, requested using the University of Utah’s interlibrary loan system. Once all of the articles were acquired, the researchers independently conducted a full review of the content of each article to ensure that they all met the inclusion criteria. Final evaluation occurred during the coding process since article evaluation tends to be an iterative, rather than linear, process (Zajchowski et al., 2018). 2.4.4.3 Data Items The studies that were included in this scoping review were coded according to the data items listed in Table 2.4, which focused on evaluating the characteristics of the existing literature, in alignment with this review. To ensure replicability of this analysis, all of the data points except for the sample characteristics were coded according to how the researcher(s) presented the data, regardless of consistency or quality of reporting on the part of the researcher(s). Sample characteristics, such as sample size, age, and gender, were only modified if the researcher(s) took extra steps to separate their sample into subgroups and in doing so made the representation of their data in a scoping review 35 Table 2.4 Coding Concept Publication Information Sample Characteristics Recreation Characteristics Social Outcome(s) Study Characteristics Study Finding(s) Codes Author(s), year, title, journal, volume, issue, and page number Location where the data was collected (e.g., city, region, park name, etc.), participation eligibility (e.g., veterans, people with anxiety, university students, etc.), sample size, age, gender/sex, and race/ethnicity/nationality How nature-based recreation was conceptualized (e.g., outdoor recreation, adventure programs, forest bathing, etc.), how nature-based recreation was operationalized (e.g., a backpacking trip, gardening, etc.), duration of the recreation experience, solo vs. group-based recreation, facilitated vs. not facilitated recreation, and whether the facilitation was by a profit vs. nonprofit entity What social outcome(s) was identified (e.g,. social cohesion, social support, etc.), and how the social outcome was measured What theory/model/framework informed the study design, method (e.g., qualitative, quantitative, or mixed), study design (e.g., pre-post test, longitudinal, case study, etc.), and analysis type Qualitative themes that emerged and/or quantitative findings related to social outcomes, and study limitations excessively detailed. For example, if a researcher broke down the number of participants within various age ranges and listed the exact number of men and women in each age range, only the highest and lowest value of the age range and the total number of men and women in the sample were coded. 2.4.4.4 Data Synthesis In the final report of the findings, data are displayed in tables that are grouped according to the research design (e.g., qualitative, quantitative, or mixed) and listed in 36 alphabetical order. While all of the coding variables are reported throughout the body of the results and discussion, the tables only include certain predetermined data points to provide an effective visual representation of the core characteristics of the data. Previous scoping reviews have comparably presented the data (Gillespie et al., 2017; Sasseville, Chouinard & Fortin, 2018), establishing a precedent for including only the data points listed in Table 2.5. In addition to the tables outlining the core characteristics of the literature, thick description regarding the findings of the scoping review focus on themes that emerged, as well as noteworthy trends and outliers regarding the characteristics of the literature. 2.5 Results and Discussion The initial database and journal search produced 7,343 articles. After removing duplicates, 5,330 articles remained. Title and abstract evaluation further reduced the number of articles to 286. After the full-text review, which included an in-depth analysis of sample characteristics and research methods, 78 articles remained. Article evaluation Table 2.5 Codes that are presented in the final data report tables Concept Publication Information Sample Characteristics Recreation Characteristics Social Outcome(s) Study Finding(s) Codes Author(s) and year Participation eligibility (e.g., veterans, people with anxiety, university students, etc.), sample size, age, gender/sex, and race/ethnicity/nationality How nature-based recreation was conceptualized What social outcome(s) was identified Qualitative themes that emerged and/or quantitative findings related to social outcomes 37 during the coding process further reduced the number of articles included in the review, resulting in a final count of 61 articles listed in Tables 2.6, 2.7, and 2.8. Articles were evaluated based on the predetermined inclusion and exclusion criteria. Common reasons for article elimination included social factors producing NBR outcomes (instead of the other way around), samples that included people under 18 years of age (particularly within the Outdoor Education and Wilderness Therapy literature), and NBR that produced an economic outcome instead of a social outcome. When considering the characteristics of the literature, the diversity of ways researchers have conceptualized NBR stood out as particularly meaningful. For example, some researchers focused on unstructured exposure to nature-based environments, including everything from general contact with nature (Soga et al., 2017) to green space exposure (Bell, Westley, Lovell, & Wheeler, 2018). Others looked at highly structured and activity-focused forms of NBR, such as outdoor sports (Lundberg, Taniguchi, McGovern, & Smith, 2016) and summer camp experiences (Dawson & Liddicoat, 2009). Despite the complex differences regarding how NBR has been conceptualized, similar social outcomes have been produced: so much so, in fact, that these same examples that demonstrate the diversity of NBR conceptualization respectively focus on social cohesion, interaction, connectedness, and meaningful community membership. Even when the conceptualization of NBR was shared, the operationalization of NBR varied tremendously within the literature. As the articles were coded according to the terminology used by the researcher(s), some were referred to as “adventure” programs, while others were called “outdoor” programs, and still other researchers connected the two terms and called them “outdoor adventure” experiences. “Adventure” 38 Table 2.6 Data report table for qualitative studies Author(s) & Year Participant Eligibility Sample Characteristics 87 people, Adams, M. & People with Mean age 43.88, Morgan, J., experiences of Age range 20-73 2018 mental illness 61F 26M Anderson, G. S. & Frison, D., 1992 Second-year university students 16 people NBR Conceptualization Nature-based intervention Adventure-based programs Social Study Finding(s) Outcome(s) 1) Participants enjoyed and valued sharing positive Social experiences with contact others 2) An increased willingness and ability to engage in social contact 1) Increased trust 2) Increased Cooperation social comfort and group 3) Decreased fear cohesion of self-disclosure 4) Increased group cohesion Aubrey, A. & 20 people, Single mothers Wilderness 1) Strong group MacLeod, M. Age range 20-50, Inclusion on welfare experience bonding J., 1994 20F Bennett, J. L., Van 28 people, 1) Being around Puymbroeck, Veterans with Therapeutic Age range 22-50, Reconnection similar others M., Piatt, J. disabilities recreation program 8F 20M 2) Social support A., & Rydell, R. J., 2014 8 people, 1) Increased Gay/bisexual Mean age 43, Age Bidell, M. P., Adventure-based Social socialization men living with range 38-54, 8M, 2010 counseling support 2) Enriched social HIV/AIDS Hispanic=3 interactions Caucasian=5 1) Social gathering of friend/acquaintan ces with similar Gathering Bricker, K. S. 593 people, Mean goals and making Kayakers and Whitewater place and & Kerstetter, age 36, new friends rafters recreation social D. L., 2002 225F 368M 2) An enjoyment appreciation for seeing others enjoy the river environment 1) Decreased Caddick, N., 15 people, Age social isolation Smith, B., & Combat Nature-based range 27-60, Wellbeing through Phoenix, C., veterans physical activity 15M relationships with 2015 other veterans 39 Table 2.6 Continued Author(s) & Year Participant Eligibility Chesler, N. C., Female tenureSingle, P. B., track & Mikic, B., engineering 2003 faculty Sample Characteristics 14 people Cooley, S. J., Holland, M. J. G., Cumming, Undergraduate 40 people, Mean J., Novakovic, engineering age 20.55, E. G., & students 8F 32M Burns, V. E., 2014 Dawson, S. & 27 people, Age Campers with Liddicoat, K., range 19-76, 17F cerebral palsy 2009 10M Dietrich, Z. C., Joye, S. W., & Garcia, J. A., 2015 Post-9/11 combat veterans 6 people, Age range 28-46, 1F 5M, Caucasian=6 Garst, B. A., 38 camping Williams, D. People camping groups, Mostly R., & at developed 40-49 (33%), Roggenbuck, campsites 45%F 55%M, J. W., 2010 White=99% Goodwin, D., Peco, J., & Ginther, N., 2009 Adults with spinal cord injuries NBR Conceptualization Social Study Finding(s) Outcome(s) 1) Loss of Psychosocial isolation and 2) Community Adventure education instrumental and trust 3) benefits Commitment to others Outdoor adventure education Summer camp Wilderness experience Camping 4 people, Age range 27-57, 2F Outdoor recreation 2M, Caucasian=4 1) Groupwork 2) Improved Interpersonal relationships outcomes 3) Internationalizatio n 1) Camp is like home 2) Being Sense of respected community members of a community 3) An opportunity to see friends 1) Building relationships with Social the hiking group reconnection members and with strangers along the trail 1) Activities were almost always social Social 2) Camping interaction positively influenced family interaction 1) Trust in the sherpas and feeling safe and comfortable as essential to Interdepende having a positive nce hiking experience 2) Socialization as an important component of the hiking program 40 Table 2.6 Continued Author(s) & Year Human, L., 2012 Participant Eligibility Counseling psychology students Sample Characteristics 19 people, Age range 22-47, 15F 4M, White=14 African=3 Coloured=1 Indian=1 NBR Conceptualization Adventure-based experience Social Outcome(s) Trust and cohesion Johnson, J. & Chin, J. W., 2016 Varsity athletes 16 people, Age range 19-26, 8F 8M, White=12 Other=4 Adventure-based orientation Team bondingcohesion Lundberg, N., Taniguchi, S., McGovern, R., & Smith, S., 2016 Martin, B., Groff, D., & Battaglini, C., 2014 Mowatt, R. A. & Bennett, J., 2011 Female veterans with posttraumatic stress and military sexual trauma 9 people, Age range 26-55, Mean age 39, 9F Outdoor sports and recreation Social support and bonding Women recovering from breast cancer 38 people, Mean age 52, 38F Challenge course Mutual support Veterans with PTSD 67 people Therapeutic flyfishing Camaraderie Mykletun, R. J. & Mazza, L., 2016 Adventure expedition teams 7 teams of four people Adventure race The creation of "communita s" Study Finding(s) 1) Students learned about trusting themselves, others, and processes that unfold 2) Students experienced group cohesion 1) Increased support, friendship, respect, and compassion 1) A positive and supportive atmosphere 2) Authenticity and connectedness 1) Shared support among people with similar experiences 1) Veterans and enlisted personnel sought or responded to interaction with other veterans or enlisted personnel 1) Enhancement of trust, reciprocal understanding, support, shared suffering, and social bonding 41 Table 2.6 Continued Author(s) & Year Participant Eligibility Quezada, R. L. & Undergraduate Christopherso students n, R. W., 2005 Rogers, S. D., Loy, D., & Injured military Brownmembers Bochicchio, C., 2016 Schwartz, G. M. & Older adults Campagna, J., 2008 Stuhr, P. T., Lecomte, H., Undergraduate & Sutherland, students S., 2017 Wallace, K. G., Graham, Adults with K. M., & cancer Wonch, D., 1993 Wilson, N. W., Fleming, S., Jones, R., Clients of Lafferty, K., mental health Cathrine, K., care services Seaman, P., & Knifton, L., 2010 Sample Characteristics 30 people, 13F 17M 10 people, Age range 22-45, 1F 10M, Caucasian=9 Other=1 100 people, Age range 60-80, 65F 35M 12 people, Age range 18-24, 4F 8M NBR Conceptualization Social Study Finding(s) Outcome(s) 1) Built community 2) Learned patience, persistence, tolerance, flexibility and how to have fun Cognition in the group Adventure-based and growth, context service learning Collaboration 3) Group skills members mutually benefited from each others' contribution 4) Learned that relationships are the key to success Development 1) Building of a social relationships Outdoor recreation community 2) Interconnection among through military participants service and injury 1) Chance to Active outdoor Belonging to make new friends leisure a group and meet more people Outdoor adventurebased experiences 24 people, 12 age 18- 40, 12 age Outdoor experiences 40+, 18F 6M 28 people, Mean age 41.9, 10F 18M Ecotherapy Friendship 1) Social connection 2) Social support Social support 1) Reduced social isolation 2) A sense of community Social 1) Increased networking social and social networking, skills social skills development, development Team 2) Improved, building and therapeutic social relationship inclusion, 3) Bridged gap Stepping between selfstone to imposed isolation further and reintroduction community to wider society engagement 42 Table 2.7 Data report table for quantitative studies Author(s) & Year Participant Eligibility Sample Characteristics Banaka, W. H. & Young, D. W., 1985 Chronic psychiatric patients 78 people, Mean age 30, 35F 43M Bennett, J. L., Lundberg, N. Veterans with R., Zabriskie, disabilities R., & Eggett, D., 2014 34 people, Mean age 37, Caucasian=18 African American=7 Hispanic=7 Other=2 Bloemhoff, H. J., 2016 Adult learners in a business school 140 people, Age 23+ Cooley, S. J., Burns, V. E., & Cumming, J., 2016 University students 238 people, Mean age 21.48 Duvall, J. & Kaplan, R., 2014 Veterans 98 people, Age 20+, 21.6%F 78.4%M NBR Conceptualization Social Study Finding(s) Outcome(s) 1) Increased formal social interaction Adventure camp Social skills 2) Increased informal social interaction 1) Significant improvements in marital satisfaction only for the group that received, "an Marital additional Sport and recreation satisfaction emphasis on communication between couples as the focus of one dinner and evening activity" (p. 79) 1) Post-test scores of social competence for the experimental Adventure-based Social group were experiential learning competence significantly higher than control group post-test scores 1) Significant increase in Outdoor adventure Groupwork perceived use of education skills interpersonal groupwork skills 1) Significant improvements in Extended groupsocial functioning based nature Social and results recreation functioning persisted at the experiences one-month follow-up. 43 Table 2.7 Continued Author(s) & Year Participant Eligibility Eikenæs, I., Gude, T., & Hoffart, A., 2006 Patients with avoidant personality disorder Sample Characteristics Social Study Finding(s) Outcome(s) 1) Significant improvements in interpersonal problems 53 people, Mean Interpersonal 2) Significant Integrated wilderness age 36.5, 34F problems and improvements in therapy 19M socialization socialization (Neither outcome was significantly different from the control group) Gatzemann, 45 people, Mean T., Schweizer, age 22.79, Age K., & Sports students range 19-27, 48F Hummel, A., 67M 2008 Gelkopf, M., Hasson42 people, Age Ohayon, I., Veterans with range 24-59, Bikman, M., PTSD 42M, Israeli=37 & Kravetz, S., Other= 5 2013 Hickmon, W. A. Jr., Protinsky, H. O., & Singh, K., 1997 Married couples 37 couples, Mean age 32.5, Age range 21-47 NBR Conceptualization Outdoor education Interpersonal conduct and social behavior Nature adventure rehabilitation 1) Moderate improvements in Social quality social quality of of life life compared to the control group Adventure-based program Marital intimacy Interpersonal relationship Hoag, M. J., 297 people, Mean functioning, Massey, K. E., Young adult age 20.2, Age social role Roberts, S. D., wilderness range 18-34, 83F Wilderness therapy performance, & Logan, P., therapy clients 224M, and 2013 Caucasian=88% therapeutic alliance No significant changes 1) Significant improvements in intimacy compared to the control group that did not receive counseling, but not significantly different from a control group that received traditional counseling 1) Significant improvements in interpersonal relationship functioning 2) Significant improvements in social role performance 3) Significant improvements in therapeutic alliance 44 Table 2.7 Continued Author(s) & Year Kelley, M. P., Coursey, R. D., & Selby, P. M., 1997 Lindenmeier, D. K., Long, T. D., & Robertson, T. P., 2004 Lundberg, N., Bennett, J., & Smith, S., 2011 Ng, H. A., 2001 Rosenberg, R. S., Lange, W., Zebrack, B., Moulton, S., & Kosslyn, S. M., 2014 Schary, D. P., Lewis, A. B., & Cardinal, B. J., 2015 Participant Eligibility Sample Characteristics NBR Conceptualization Social Study Finding(s) Outcome(s) 1) Significant improvements in People with trust and serious and 57 people, 8F Therapeutic outdoor Trust and cooperation only persistent 42M adventure program cooperation for people with mental illness schizoaffective disorders 1) Trust increased Cohesiveness for both high and , belonging, 75 people, Mean low ropes courses College socialization, age 19.94, 42F Challenge course 2) Cooperation students trust, and 28M increased only for understandin the low ropes g course 18 people, Mean age 30-34, OIF/OEF Caucasian=10 Adaptive sports and Social quality No significant veterans with Africanrecreation of life changes disabilities American=4 Hispanic=2 Other=2 1) Modest, 345 people, 49% significant age 20-34, 18%F increase in social 82%M, Social Organization support Chinese=70% Adventure learning support and employees 2) Modest, Malay=20% team spirit significant Indian=7% increase in team Other=3% spirit 1) Improvements in alienation compared to 199 people, Age Alienation Cancer Outdoor adventure control group range 18-39, 165F and feelings survivors programs 2) No significant 34M of isolation changes in feelings of isolation 1) Communication, collaboration, and Communicati social 375 people, Mean on, responsibility University Outdoor adventure age 21.1, 257F collaboration, increased, but at students education 118M and social three months responsibility follow up improvements were not sustained 45 Table 2.7 Continued Author(s) & Year Sample NBR Characteristics Conceptualization 40 people, Mean Scherer, M. Wounded, ill, age 30.5, 6F 34M, R., Gade, D. and injured Caucasian=31 M., & active duty and African Adaptive athletics Yancosek, K. veteran service American=4 E., 2013 members Hispanic=8 Asian=1 Soga, M., Cox, D. T. C., Yamaura, Y., 332 people, Mean Allotment Gaston, K. J., age 61.45, 144F Contact with nature gardeners Kurisu, K., & 177M Hanaki, K., 2017 Wheeler, S., Goldie, J., & Hicks, C., 1998 Participant Eligibility Second-year counselor trainees 17 people, Age range 28-56, 14F 3M Outdoor development Zebrack, B., 304 people, Age Kwak, M., & Young adult range 18-40, 249F Outdoor recreational Sundstrom, L., cancer patients 49M, White=239 activity 2017 Other=53 Social Study Finding(s) Outcome(s) Social interaction Social cohesion Sense of being able to help others and awareness of interpersonal group processes Social support No significant changes 1) Gardeners, compared to nongardeners, reported significantly greater social cohesion 1) Increased sense of being able to help others 2) No significant change in awareness of interpersonal group processes 1) Distressed participants reported a significantly greater increase in social support at posttrip and 1 month later when compared to nondistressed participants Table 2.8 Data report table for mixed method studies Author(s) & Year Participant Eligibility Sample Characteristics NBR Conceptualization Anderson, L., Schleien, S., Adults with and 26 people, Age McAvoy, L., without range 22-65, 13F Lais, G., & disabilities 13M Seligmann, D., 1997 Integrated outdoor adventure program Social Study Finding(s) Outcome(s) 1) Increased group cohesion 2) Increased Relationship willingness to development include others and social 3) Positive integration changes in social activity and interpersonal relations 46 Table 2.8 Continued Author(s) & Year Participant Eligibility Sample Characteristics Bell, S. L., Westley, M., Lovell, R., & Wheeler, B. W., 2018 Residents of Cornwall 33 people, Age range 25-85, 20F 13M Male contemporary 44 people, Mean Bird, K., 2015 returned postage 43.3, Age deployed range 31-66, 44M veterans Breunig, M. C., O'Connell, T. S., Todd, S., Anderson, L., & Young, A., 2010 College students 98 people, Mean age 22.9, Age range 19-52, 55F 43M Bryson, J., Feinstein, J., Spavor, J, & Kidd, S. A., 2013 Adults with psychosis 15 people, Mean age 35.2, Age range 24-48, 4F 11M NBR Conceptualization Social Study Finding(s) Outcome(s) 1) Shared wildlife encounters Green space Social 2) Wildlife experiences experiences encounters catalyzed social interaction 1) No significant changes in family, friend, or spouse interactions 2) Increased Social feelings of interactions comfort, Peer outdoor support and familiarity, and therapy program connecting closeness with with others others on the trip 3) Sense of belonging 4) Increased ability to selfdisclose 1) Significant Sense of changes in sense community of community 2) Outdoor pursuits and group Significant cohesion changes in group cohesion 1) No significant changes in social Social functioning functioning Adventure-based 2) Teamwork, and forming therapy belonging, new support, and connections making new friends Second-year physical Gordon, B. & 16 people, Age education Dodunski, R., range 19-25, 12F majors at New 1999 4M Zealand University Outdoor education Greffrath, G., Meyer, C., Strydom, H., & Ellis, S., 2011 1) Improvement Social in social abilities Center-based abilities, 2) Improvement adventure program social in social and an expedition- effectiveness, effectiveness based wilderness and 3) Improvement program cooperative in cooperative teamwork teamwork improved Third-year university students 28 people, Age range 20-23, 14F 14M Perceptions of peers 1) Improved group dynamics and group bonding 47 Table 2.8 Continued Author(s) & Year Participant Eligibility Sample Characteristics NBR Conceptualization Harper, N. J., Norris, J., & D'astous, M., 2014 Veterans 54 people, Age range 20-77, 7F 47M Wilderness-based adventure training Hatch, K. D. & McCarthy, C. J., 2003 Graduate counseling students 12 people Experiential groups Hawkins, B. L., Townsend, J. A., Heath, S. E., & Lipton, K., 2018 Military families 70 families, Mean age 36.9, Age range 24-55, 52.5%F 47.5% Recreation-based program Jakubec, S. L., Carruthers 37 people, 66% Adults with Den Hoed, D., less than age 35, disabilities and Ray, H., & 34% age 35+, their caregivers Krishnamurth 63%F 37%M y, A., 2016 Nature experiences Mapes, N., 2012 People with dementia 24 people Woodland recreation McAvoy, L., Smith, J. G., & Rynders, J. E., 2006 People with cognitive disabilities 23 people, Age range 21-62, Mean age 38.5, 5F 18M Outdoor adventure programs Social Study Finding(s) Outcome(s) 1) Significant Effective improvements in communicati communication on, group and collaboration collaboration, 2) Increased camaraderie, camaraderie and healthy 3) Supportive and community understanding community 1) Increased Group teamwork 2) functioning Increased group cohesion 1) No statistically significant changes in family functioning 2) Family Family interactions 3) functioning Connection with military community and resources 4) More family communication 1) A nonSatisfaction statistically with friends increase in and satisfaction with community, friends and and community reimagined 2) New social experiences of relations self and others 1) Sense of belonging 2) Sense of friendship and kinship Social 3) Community benefits presence and activity 4) Co-incidental positive social encounters 1) Participants learned and Socialization practiced skills appropriate social skills 48 Table 2.8 Continued Author(s) & Year Sample Characteristics 35 people, Median age 27, University 91%F 9%M, Norton, C. L. students taking Caucasian=43% & Tucker, A. a groupwork Hispanic=29% R., 2010 Social Work African class American=14% Other=14% Warber, S. L., Dehudy, A. A., Bialko, M. F., Marselle, M. R., & Irvine, K. N., 2015 Participant Eligibility Young adult campers and staff 36 people, Age range 18-31, 67%F 33%M, United States=35 United Kingdom=1 Woodford, K. M., Fenton, Adult inpatients 24 people, Age L., & with mental range 19-58, 11F Connors, J., illnesses 13M 2017 NBR Conceptualization Adventure-based group work Social Study Finding(s) Outcome(s) Group cohesion Nature exposure Positive relationships with others and social connection Wilderness therapy Social skills 1) Statistically significant increase in group cohesion 2) Group cohesion emerged as a theme 1) Positive relations with others approached but did not reach statistical significance 2) The wilderness environment facilitated interpersonal connection 1) Decreased isolation 2) Increased group cohesion and connectedness programs constituted the most common conceptualization of the NBR experience within this review, as illustrated in Figure 2.1, but the operationalization varied dramatically from one study to the next. In 1997, Anderson, Schleien, McAvoy, Lais, and Seligmann conducted a study to assess social outcomes associated with an adventure program for adults with and without disabilities. In their study, participants went canoeing for 3-6 days throughout the Midwestern United States. In 2016, however, when Bloemhoff evaluated the social outcomes of an adventure program, it consisted of a single-day ropes course experience in South Africa. Technically, both experiences relied on the natural environment, but the depth of exposure to the natural world and extent of removal from built human environments differed greatly. Still, both studies managed to identify 49 Other 20% Adventure 26% Sports & Athletics 5% Nature-Based 10% Outdoor 18% Wilderness 8% Outdoor Adventure 13% Figure 2.1 Conceptualization of nature-based recreation beneficial social outcomes associated with NBR participation. Within the qualitative literature, social connection, social interaction, community, and camaraderie surfaced as common themes. Qualitative findings indicated that NBR provides the opportunity for people to gather together (Bricker & Kerstetter, 2002), experience reduced social isolation (Bidell, 2010; Caddick, Smith, & Phoenix, 2015; Wallace, Graham, & Wonch, 1993), and enhance perceptions of social support (Lundberg et al., 2016; Martin, Groff, & Battaglini, 2014). Less frequently, qualitative research has found that social skills improve through participation in NBR. For example, Human (2012) found that “students learned about trusting themselves, trusting other people, as well as trusting the process that unfolds between people in a helping relationship” (p. 593). Similarly, Quezada (2005) found that students developed collaboration skills 50 through participation in NBR, which included improvements in, “patience, persistence, tolerance, flexibility, and how to have fun” (p. 9). Overall, existing qualitative findings seem to indicate NBR contributes to positive changes in social interaction, connection, cohesion, and support, as well as improvements in various skills required for successful social engagement. The quantitative research differed from the qualitative research primarily in demonstrating a more equitable balance between research that focused on social skill development and research that evaluated perceptions of group cohesion and social support. Regarding social skill development, quantitative literature has evaluated outcomes related to cooperation (Kelley, Coursey, & Selby, 1997), interpersonal/social functioning (Duvall & Kaplan, 2014; Eikenæs, Gude, & Hoffart, 2006; Gatzemann, Schweizer, & Hummel, 2008; Hoag, Massey, Roberts, & Logan, 2013), groupwork skills (Cooley, Burns, & Cumming, 2016), and social competence (Bloemhoff, 2016). The quantitative literature aligned with the qualitative findings in its tendency to focus on social quality of life (Gelkopf, Hasson-Ohayon, Bikman, & Kravetz, 2013; Lundberg, Bennett, Smith, 2011), group cohesion (Lindenmeier, Long, & Robertson, 2004; Soga et al., 2017), and social support (Zebrack, Kwak, & Sundstrom, 2017), but also uniquely incorporated marital satisfaction and intimacy (Bennett et al., 2014a; Hickmon, Protinsky, & Singh, 1997). The mixed methods studies in this area of research demonstrated a balanced evaluation of both social skills (Bryson, Feinstein, Spavor, & Kidd, 2013; Greffrath, Meyer, Strydom, & Ellis, 2011; Harper, Norris, & D’astous, 2014; McAvoy, Smith, & Rynders, 2006; Woodford, Fenton, & Connors, 2017) and the quality of social 51 experiences (Anderson et al., 1997; Bell et al., 2018; Breunig, O’Connell, Todd, Anderson, & Young, 2010; Bryson et al., 2013; Gordon & Dodunski, 1999; Jakubec, Carruthers Den Hoed, Ray, & Krishnamurthy, 2016; Mapes, 2012; Norton & Tucker, 2010; Warber, Dehudy, Bialko, Marselle, & Irvine, 2015). The mixed methods portion of the literature’s only evident distinguishing quality regarding the social outcomes evaluated was placing a greater emphasis on social outcomes related to family functioning (Bird, 2015; Harper et al., 2014; Hawkins, Townsend, Heath, & Lipton, 2018). When interpreting the findings of existing research in this topic area, however, it is worth noting that within the studies reporting whether the recreation experience occurred in a group or solo setting, all but one of the forms of NBR exclusively occurred within a group context. Even within the single study that specified their incorporation of solo NBR experiences, the recreation included group experiences as well (Bell et al., 2018). Furthermore, only three studies evaluated social outcomes for forms of NBR that were not facilitated (Bell et al., 2018; Garst, Williams, & Roggenbuck, 2010; Soga et al., 2017), and one study looked at forms of NBR that were both facilitated and not facilitated (Bricker & Kerstetter, 2002). Every other study looked at facilitated NBR experiences. Therefore, social outcomes resulting from NBR might be impacted by the group-based setting and the facilitation process. Without additional information, the impact of these social processes cannot be separated from the outcomes NBR experiences seem to produce. In looking at the eligibility criteria for research participation throughout existing literature, people with disabilities occupied the largest portion of study participants, as 52 evidenced in Figure 2.2. Also, many of the studies evaluate outcomes for participants who are members of the veteran and military community. While some of the research focused on veteran and military community members with disabilities, not all of the research that focused on this population required that their participants meet criteria for a particular diagnosis or have a specific injury. A finding that tends to be common throughout research in general and, therefore, was not a surprise within this analysis, was the oversampling of university students. One might consider how certain social outcomes, such as developing a sense of community and increased social support, might differ if the participant samples within each study did not tend to share significant components of their identity and developmental stage. As it stands within the existing literature, 80% of research participants are known to share at least one major component Other 10% People with Disabilities 31% Recreationists 10% University Students 26% Veterans & Military 10% Figure 2.2 Eligibility criteria Veterans & Military with Disabilities 13% 53 of their identity, either as people with disabilities, members of the veteran and military community, or university students, many of whom were taking a single class together when the research was conducted. However, a small portion of researchers focused on general recreationists through the on-site sampling of kayakers, gardeners, campers, etc. Others looked at groups that were otherwise not represented in the literature, such as older adults, organization employees, and single mothers. Future research may benefit from looking beyond people with disabilities, members of the veteran and military community, and university students to identify the value of nature-based recreation in producing social benefits for a broader swath of the general public. Sample characteristics in the literature demonstrated certain weaknesses. For example, only 16 of the studies reported the race, ethnicity, and/or nationality of their research participants. Within the studies that reported the race or ethnicity of their sample participants, people who are White/Caucasian were disproportionately represented (83%). Without having information regarding the diversity of participants and when samples disproportionately include people from a White/Caucasian background, the generalizability of findings is limited. Additionally, many of the studies that have been conducted (46%) include fewer than 30 people in their sample, followed by sample sizes of 31-60 people (26%), 61-100 people (13%), and 100+ people (15%). While sample sizes tend to be less of a concern when utilizing a qualitative approach, 38% of existing studies utilized either quantitative or mixed methods to evaluate outcomes for samples of fewer than 60 people. This may reflect potential inherent difficulties associated with recruitment and sampling for NBR studies. 54 Regarding methods, existing research on the social outcomes of NBR was fairly equitably distributed between qualitative, quantitative, and mixed methodological approaches. Forty-one percent of the research utilized a qualitative approach, followed by quantitative methods with 33%, and mixed methods coming in last at 26% of the research. Thematic analysis was conducted by 38% of the researchers, making it the most commonly used analysis type within this topic area. The use of ANOVA, ANCOVA, MANOVA, and/or MANCOVA came in second at 18%, and, less often, t-tests (13%) and constant comparison (7%) were implemented in the data analysis process. One-third of the studies did not provide specific information regarding study design (e.g., case study, pre-post test, phenomenology, etc.), which researchers would benefit from recognizing and correcting going forward. Furthermore, only 9 of the 61 studies explicitly articulated the use of a theory, model, or framework to inform study design. Therefore, the research on this topic area appears to be overwhelmingly atheoretical, and future research would benefit from bolstering the quality and validity of study findings by basing study design, analysis, and interpretation on a solid theoretical foundation. 2.6 Conclusion The intent of this scoping review was to evaluate the current state of the literature regarding the social outcomes of participating in nature-based recreation with a particular emphasis on identifying the characteristics of the literature. The specific methods that were used followed the precedent established by previous scoping reviews (Gillespie et al., 2017; Sasseville et al., 2018; Zajchowski et al., 2018) and adhered to the rigorous process required by the PRISMA-P 205 protocol (Moher et al., 2015). This level of 55 methodological systematization and rigor ensured validity and allows for the possibility of future replicability. Findings indicate that existing research has demonstrated certain strengths, such as diversity and complexity in the ways that NBR has been conceptualized and operationalized; a balanced utilization of quantitative, qualitative, and mixed methods; and looking at the social outcomes of NBR for men, women, and mixed gender groups. Also, researchers have somewhat equitably evaluated both the quality of social experiences and changes in various social skills. However, weaknesses in existing research include lack of theory; limited or absent information regarding study design; lack of information regarding the race, ethnicity, and nationality of research participants; and an overwhelming tendency to sample people with disabilities, university students, and members of the veteran and military community. Weaknesses in these areas limit the generalizability of findings and restrict our understanding of the mechanisms that produce social outcomes in NBR settings. Also, if the samples contained a diverse collection of people with a range of abilities, experiences, and education levels, the social outcomes of the research studies might have been different. Existing research focuses almost exclusively on facilitated and group-based NBR experiences, which could be confounding variables that significantly influence social outcomes. Without conducting studies with control groups that are solo and not facilitated, we cannot conclusively attribute the social outcomes to the NBR itself, rather than the group experience. Future research regarding the outcomes of participation in nature-based recreation may benefit from evaluating the social outcomes from NBR experiences that are not 56 facilitated, do not occur in a group context, and are not exclusively provided to a sample of people who all share a major preexisting identity. Also, future research should recognize the deficiencies in the reporting processes of existing research to enhance the quality and depth of information available, specifically regarding sample characteristics and study design. Additionally, future research may benefit from emulating the positive qualities of the existing literature by taking a balanced methodological approach and using qualitative, quantitative, and mixed methods, as well as looking at both social skills and the quality of social experiences. Producing additional information about the potential value of NBR for enhancing family functioning and marital intimacy may also prove beneficial, given the fact that only a few existing studies have specifically focused on these social outcomes. CHAPTER 3 THE SOCIAL BENEFITS OF A RIVER RAFTING TRIP FOR VETERANS WITH POSTTRAUMATIC STRESS DISORDER 3.1 Introduction As many as 30% of U.S. military veterans experience posttraumatic stress disorder (PTSD) during their lifetime (National Center for PTSD, 2018), which far exceeds the 6.8% prevalence rate of PTSD among the general U.S. population (National Institute of Mental Health, 2017). The experience of PTSD among veterans, particularly when combined with other co-occurring mental health conditions, can lead to challenging difficulties in important social relationships, such as persistent isolation, increased sense of loneliness, elevated risk of divorce, increased conflict in intimate partnerships, avoidance of meeting new people, decreased satisfaction in parenting, and an inhibited capacity to self-disclose in friendships (Rodriguez, Holowka, & Marx, 2012). Furthermore, negative social responses to disclosures of details related to traumatic events (Herman, 2015) and limited social support (Kaniasty & Norris, 2008) have been correlated with an increased risk of PTSD diagnosis, in addition to the exacerbation and persistence of existing PTSD symptoms. The well-intentioned but somewhat unhelpful belief that receiving assistance limits the availability of quality services for fellow veterans often creates barriers to care 58 for many people who have served (Tanielian & Jaycox, 2008). Also, widespread stigma within the veteran and military community associated with receiving mental health services discourages many veterans from receiving traditional mental health treatment services (Tanielian & Jaycox, 2008). Fortunately, a growing body of evidence indicates that nontraditional, and therefore less stigmatized, nature-based recreation opportunities may provide salutary benefits (van den Bosch & Bird, 2018), including but not limited to improvements in psychological wellbeing and social functioning (Duvall & Kaplan, 2014). River-based recreation experiences, in particular, have been identified as a form of nature-based recreation that has demonstrated promise in reducing PTSD symptoms and increasing social interaction among service members with disabilities (Scherer, Gade, & Yancosek, 2014). Among the few studies that have attempted to address river running as a potentially restorative environment for veterans with PTSD, quantitative methods have largely been used (Scherer et al., 2014) and the lasting social benefits of river trips have not been systematically analyzed (Dustin et al., 2011). Furthermore, current research does not provide the richness of information from the perspective of the participants about the social benefits and drawbacks of river running. For example, little is known about what participants tend to value in river-based recreation settings, what type of social groups (e.g., group size, gender composition, service experience, etc.) cultivate optimal social support networks, what factors influence how social dynamics evolve among veterans in these settings, whether social support continues beyond the immediate setting, and which specific elements of nature-based interventions are particularly useful or harmful from the perspective of the participants. 59 By gaining a better understanding of participant perceptions regarding the social environment that emerges during these trips and the lasting social support it may provide, guiding companies, trip facilitators, and recreational therapists can provide the best possible services for veterans with PTSD. Given the tremendous value of experiencing robust social support among this population, optimizing the facilitation of river trips might lead to enhanced perceptions of social support that have the potential to reduce PTSD symptoms and improve health and wellbeing. Therefore, the purpose of this study was to gain a better understanding of participants’ perceptions and evaluations of the social environment that emerged during a river rafting experience, as well as the durable benefits that the social environment on the river rafting trip provided. 3.2 Research Questions 1. What social environment emerges during a river rafting trip for veterans with PTSD? 2. How does an individual’s personal experience and/or social location (e.g., gender, age, service experience, etc.) impact their engagement in the social context that emerges? 3. What short-term and/or long-term perceived benefits does the created social network provide? 60 3.3 Methods 3.3.1 Paradigm To gather information about the emerging social environment among veterans with PTSD during a river trip, my engagement in the group dynamics was expected to inevitably occur. While a researcher should not necessarily seek to place themselves as a central feature of the social dynamics that evolve during a study, conversations between myself and participants while camping, sharing meals, hiking, and floating down the river were expected to influence the overall group interaction. Also, the interviews took place during the 3rd day on the river, so the participants were reasonably familiar with me and we had some shared experiences before they answered questions about the social environment that emerged. Consequently, familiarity and interaction were expected to result in the co-creation of meaning throughout the data gathering process and, therefore, the study benefited from the use of a constructivist paradigm. Ontologically, constructivism takes a relativist approach that focuses on shared understanding, as well as individually and socially constructed realities. According to Ponterotto (2005), “constructivists hold that reality is constructed in the mind of the individual, rather than it being an externally singular entity” (p. 129). Not all participants viewed the river trip’s social environment in the same ways. While there were similarities among participants, there were a variety of equally valid ways of engaging with and interpreting what occurred socially during the river trip. These differing opinions emerged in participant conversations, behavior, writing, and interviews and were acknowledged in the interpretation and presentation of data. 61 The findings presented in this research, rather than being viewed as an objective reality, should be understood to be the product of what was created through researchersubject interaction. The constructivist axiology rejects the possibility of neutrality and openly acknowledges the values of the researcher and the participants. Instead of trying to control for personal biases and assumptions, constructivism openly acknowledges their impact on the findings. 3.3.2 Researcher as Instrument When using a constructivist paradigm that acknowledges the researcher’s cocreation of meaning with the subjects, understanding the researcher’s underlying perspective, experiences, assumptions, and biases becomes critical to data comprehension and interpretation. Marshall and Rossman (2016) articulate the importance of selfdisclosure in this context when they state, “[one’s identity, experience, and values] should be articulated as elements of the researcher role, access, ethics, entry… and also data management, analysis, and reporting… When they are out in the open, they are more manageable and the reader of the final report can assess how those elements of identity affected the study” (p. 177). In the context of this particular study, my social identity impacted the collection and interpretation of data, as well as the study outcomes. Marshall and Rossman (2016) note that “when the researcher shares an aspect of social identity – gender, for example – with participants, he should be cautious about assuming that he understands the interview partner’s experience just because he’s a man, too” (p. 163). In this case, I share the experience of having PTSD, as well as enduring a significant transition back to life in the 62 United States after returning from challenging international experiences. While the veterans in this study served overseas in a military capacity, I was involved in humanitarian work. Additionally, I identify as an American, female, civilian, researcher, and student. Some of these primary identities were shared by the participants and inevitably influenced the social environment that emerged, in addition to the quality and nature of the data that were collected. While lacking history as a service member, my personal experiences with PTSD cause me to carry assumptions about how PTSD can prove challenging during daily life experiences. For example, I hold the opinion that crowded, noisy, and novel social environments can be particularly challenging for people who are actively experiencing PTSD symptoms. Also, through an understanding of current PTSD research, I have an attentional focus on the problems created by an absence of social support and the widespread social isolation tendencies many veterans with PTSD experience. Therefore, my primary concern within this research is the negative impact social isolation can have on an individual’s health and wellbeing, as well as the way unmet needs for social support can exacerbate PTSD symptoms. Additionally, I view mental illness largely as an adaptive response to disruptive circumstances and perceive it to be a very normal and reasonable part of life. While I acknowledge that my presence impacted group dynamics, the guides and the veterans were considered to be the primary contributors to the social environment that emerged. However, even passive social involvement impacted the social dynamics that emerged during the river trip. Also, to maintain a deep, rich understanding of how my personal processes, assumptions, and biases influenced the study, I kept a self-reflective 63 journal that focused on these components of the research process. 3.3.3 Participants To recruit participants effectively, efficiently, and from a variety of backgrounds, mixed-purpose sampling, including both maximum variation and purposeful snowball sampling, were used. To maximize participant diversity, informational flyers were provided to VA hospitals throughout the country, as well as local and national organizations that have a reputation of more specifically focusing on the needs of younger veterans. Additionally, organizations that provide specialized services for veterans with a variety of illnesses and disabling conditions were invited to assist in sharing about the trip with people who might qualify for, be interested in, and benefit from the river trip experience. Also, to not limit the search to a particular geographical region, information about the study was circulated on Facebook (VeteransUtah, 2018) using paid advertisements targeted at U.S. military veterans. Once participants started to express interest in the study, purposeful snowballing was used through encouraging potential participants to share information about the study with friends, family members, and/or coworkers who might qualify for and be interested in the study. This allowed the study to access veterans who might not have been actively involved in VA services, veteran-specific community-based programs, and/or view advertisements on Facebook. A specific and intentional protocol was used to ensure basic parameters were enforced that identified participant eligibility and maximized participant safety. First, the screening process involved confirming that everyone had military veteran status and 64 participation was restricted to those who had served in the U.S. forces. Additionally, given the most common unique vulnerabilities of the population, participants were screened for current substance dependence, suicidal behavior, and recent hospitalizations (Hoge et al., 2004). To ensure that all participants currently met criteria for PTSD diagnosis, the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) was used, which is considered to be the gold standard regarding accuracy and validity for PTSD diagnosis (Weathers et al., 2018). Interviews for the CAPS-5 were conducted by phone by a trained clinician associated with the National Center for Veterans Studies at the University of Utah. Individuals who had a current PTSD diagnosis according to the results of the CAPS-5 interview held military veteran status, and were not contraindicated for participation based on health concerns were invited to participate in the study. All participants were asked to participate through informed consent that aligns with the expressed requirements of the Institutional Review Board at the University of Utah. 3.3.4 Research Design A case study research design was identified as the most effective way to address the research questions for this study. According to Creswell (2012), “case study research is a qualitative approach in which the investigator explores a bounded system (a case) or multiple bounded systems (cases) over time, through detailed, in-depth data collection involving multiple sources of information (e.g., observations, interviews, audiovisual material, and documents and reports), and reports a case description and case-based themes” (p. 73). This study took place on a river rafting trip involving a group of veterans 65 with PTSD, so the trip itself provided a bounded system for the participant interactions to occur. It also satisfies the requirement of existing over time because the trip lasted 4 days with follow-up data gathered 1 month after the trip. The interviews used a topical approach, focusing on the social environment that emerged as it compared to the participants’ everyday social environment. Marshall and Rossman (2016) state that, in topical interviews, “the researcher explores a few general topics to help uncover the participant’s views but otherwise respects the way the participant frames and structures the responses” (p. 150). In the context of this study, a topical approach was used to achieve the goal of maintaining a focus on a particular issue without being too rigid to allow space for the modification of questions and expanding on conversations in unexpected, valuable ways. Case studies themselves can be categorized into intrinsic, instrumental, and collective types of studies. An instrumental case study, “focuses on an issue or concern, and then selects one bounded case to illustrate the issue” (Creswell, 2012, p. 74). Because this study sought to investigate a broader issue using a single, bounded, typical case, it functions as an instrumental case study. 3.3.5 Data Gathering Triangulation in qualitative research involves the “consistency of findings across methods and data sources” (Morrow, 2005, p. 251) and contributes to the “richness, breadth, and depth of the data gathered” (p. 256). In this study, I achieved triangulation through extensive time spent with participants in the field, the use of multiple data sources, and comparing findings from the different data sources. More specifically, I 66 spent 4 days on the river gathering participant data. The various sources of information used are listed in Table 3.1 and included field note observations, topical interviews, written logs, and social network analysis. 3.3.5.1 Interviews The primary data source was interviews that took place both during and after the river trip. Participants spent 3 full days together before conducting the interviews. The intention of waiting until the 3rd day was to provide ample time for relationships to build among participants and group dynamics to develop. The topic of focus during the interviews primarily revolved around group social dynamics on the trip compared to everyday social experiences, as well as factors that were expected to influence an individual’s social engagement in the group. Before being interviewed, participants were thanked for their participation in the study and reminded that, while welcome to do so, Table 3.1 Data sources and intervals Source Interval Interviews Topical interviews conducted during day three of the trip and one month following the trip. Documentation Free-write and prompted logs completed by participants during each day of the river trip, including the night before the trip began. Observations Field notes were written by the researcher that started during the recruitment process and continued through the termination of the river trip. Social Network Analysis A paper-based survey completed during lunch on the final day of the river trip. 67 they were not obligated to discuss details of past traumatic experiences during the interview. Permission to record the interviews was received and the interviews were recorded using two separate portable recording devices. Also, the researcher assured them they were only expected to answer the questions they felt comfortable with. Table 3.2 provides a comprehensive list of questions, and associated subquestions, that were used to guide the interviews. During each interview, I had a printed list of the questions and notes were made regarding nonverbal behaviors that could not be documented using an audio recording device. After the completion of the river trip and before they departed for home, participants were asked to schedule a convenient time for a brief follow-up phone interview 1 month after the trip. During the follow-up interview, participants were asked the questions listed in Table 3.3 that focused on the potential lasting social impact of the river trip experience. 3.3.5.2 Documentation (Prompted and Free-Write Logs) The night before the group was driven to the river, participants received a log with prompted writing questions to complete at the end of each day, listed in Table 3.4. Participants also had space in their logs, following the prompted questions, to write freely about their experiences on the trip in whatever way they chose. 3.3.5.3 Observation (Field Notes) Before, during, and after the trip, field notes regarding the research experience were kept in a small notebook. During the river trip, notes regarding objective behavioral 68 Table 3.2 Interview questions during the river trip Interview Question Sub-Question(s) Do you have any thoughts regarding your social interactions on this trip? The RQ Addressed RQ #1 Do you think being in an outdoor environment influences your social interactions? How so? Do you think having an all-veteran trip influences your social interactions? How so? Do you get along with the individuals who are on this trip? RQ #1 How would you describe the way you feel about this group? Is there anything about your personal background and experiences that you think impact your social interactions on this trip? RQ #2 How would you describe your current, everyday social life back home? RQ #2 Are you part of any groups or teams where you get to socialize regularly? How do your everyday social interactions compare to your social interactions here? Do you often spend time with people in outdoor adventure settings like this? Do you often spend time with fellow veterans or current service members? How is your social comfort level in this setting similar to or different from the social comfort level you experience during your daily life? RQ #2 Has your level of social comfort changed over the last few days? If so, how? What would be your ideal social interactions on a river rafting trip like this? Who would you ideally like to have on a river rafting trip like this? Is there an ideal combination of people that appeals to you on a river trip like this? If so, please elaborate. Is there an ideal number of people that appeals to you on a river trip like this? If so, how many? RQ #2 69 Table 3.2 Continued Do you think you will stay in touch with anyone from this trip? Why or why not? RQ #3 Do you think there could be any benefits or drawbacks to staying in touch with the people on this trip? Is there anything you think I should have asked about that I did not address? Table 3.3 Posttrip interview questions Interview Question Sub-Question(s) The RQ Addressed Looking back on the river trip, what did you enjoy about it? RQ #3 Are you still in contact with anyone from the trip? RQ #3 Did your leisure behavior change after the trip? If so, how? RQ #3 Did any of your everyday relationships change after the trip? If so, how? RQ #3 Did the river trip impact any of your family, work, or other relationships? Has the river trip changed how you feel about participating in unfamiliar social environments? If so, how? RQ #3 Is there anything else you would like to share? RQ #3 observations and subjective interpretations of individuals’ behaviors (what occurred and what meaning was drawn from it) were written about each participant each evening when I had returned to my tent. To protect the quality of the relationships with participants, notes were not taken while engaging with participants throughout each day. Also, because I had contact with participants from the first time they expressed interest in the 70 Table 3.4 Log questions Question The RQ Addressed Describe your social interactions today. Did you feel comfortable or anxious? Were there any conversations that stood out to you or were memorable? RQ #1 Do you think any demographic factors (e.g., gender, age, service experience, education, social class, race, religion, and/or ability status) impacted your social interactions today? If so, how? RQ #2 Do you think your perspective, attitude, and/or approach to this trip impacted your social interactions today? If so, how? RQ #2 Do you think any of your interactions with other members of the trip have RQ #3 had a positive, negative, or neutral impact on you today? If so, how? study, notes were also made regarding participants’ socially relevant comments and behaviors. A portion of the notebook was also dedicated to exploring my personal biases that had the potential to impact the data gathering and analysis process. Through extensive self-reflection, I increased the validity of the data by acknowledging the impact my biases had on the co-created meanings that emerged. Because this study utilized a constructivist framework, researcher engagement with, and interpretations of, the data were considered a valuable component of the research process. 3.3.5.4 Social Network Analysis On the final day of the trip, the participants received a social network analysis (SNA) form inquiring about their ideal social experience during a comparable river trip. Without considering the technical skills necessary to effectively raft down the river, and 71 focusing on the social nature of river trips, participants were asked to list two to three members of their trip they would ideally bring on another river trip. Based on the SNA prompt used by Jostad, Sibthorp, Pojha, and Gookin (2015), participants received the following prompt: Imagine you are going on a four day river trip where all required technical skills and food are taken care of. You will have plenty of time throughout the day to enjoy the company of the people around you. Name up to two to three people from this group (guides and staff included) that you would want on that trip. Why them? Findings from the SNA were triangulated with data derived from interviews, daily logs, and field notes to draw conclusions about the social environment that emerged during the trip. 3.3.6 Data Analysis 3.3.6.1 Open Coding All data were initially presented as-is, without correcting any spelling or grammar mistakes by participants in the interviews and written logs. Once the data had been fully coded and analyzed, the researcher edited quotes, as necessary, to ensure clarity and understanding. However, in such cases, any changes made were denoted using brackets in the presentation of the results. Once all data had been effectively gathered, organized, and securely stored, a fellow doctoral student was recruited to collaboratively code the data. The process began by each researcher independently engaging in open coding. During this process, “data are broken down into units of meaning (concepts), labeled (often with words close to those of the participant), and interrogated (for alternative interpretations, conditions surrounding the meaning, and gaps left unfilled)” (Fassinger, 2005, p. 160). Open coding accounts for 72 the initial development of meaning associated with interview content. 3.3.6.2 Axial Coding After the open coding, the researchers met to review the identified codes and began axial coding, “in which relationships among categories are organized and further explicated, grouping them into more encompassing (key) categories that subsume several (sub)categories” (Fassinger, 2005, p. 160). During this process, the researchers collaboratively grouped the data into thematic categories. By working together, the researchers not only increased the likelihood of noticing subtleties in the data but also used each other’s knowledge to improve the overall quality of the categorical groupings. 3.3.6.3 Selective Coding Once categorized, the themes that emerged were shared with a team of three other researchers who were familiar with the study and experienced in this type of field of research. The research team provided recommendations regarding how the themes should be effectively renamed, combined, and/or need to be parsed out into separate categories based on the content of the data that had been grouped into each category. Next, the two primary coders integrated the research team’s feedback into the organization and definition of the themes and subcategories. The data were set when the two primary researchers reviewed the data to confirm that all of the concepts within the data had been represented by the themes and subcategories that had been identified. A final version of the codes were then presented to the larger research team, which was followed by minor edits and rewording of subcategories. 73 3.3.6.4 Additional Data Analysis The SNA data analysis did not follow this same process of coding and categorization. Instead, it was used as data to supplement the information provided by the data that were coded, further contributing to the triangulation process, as well as providing a visual representation of the social environment that emerged during the trip. The responses were visually graphed, based on methods used in previous studies that utilize SNA (Jostad et al., 2015), to represent the network of relationships that developed during the river trip and the consequent preferences for whom the participants would include in a fictitious future trip. The intent of the SNA was to confirm and enhance the qualitative information about the social environment provided through interviews, logs, and field notes, following a precedent set by existing qualitative research (Jostad, Sibthorp, & Paisley, 2013). 3.4 Trustworthiness and Ethical Considerations Trustworthiness in qualitative research refers primarily to the data interpretation process and whether or not the conclusions drawn by the researcher ought to be trusted. Within the context of a constructivist paradigm, Morrow (2005) identifies, “dependability… triangulation… researcher reflexivity… praxis… verstehen… and particularity” (p. 253) as key components of trustworthiness in qualitative research. Each component plays a role in the degree to which the data collection and ultimate findings of the qualitative study can be viewed as trustworthy. In this context, dependability refers to using a systematic process to conceptualize and implement the study. This was achieved by formulating a thorough, highly structured 74 case study design. The achievement of dependability, however, required that the researcher implement the study as intended, without significantly digressing from the topic or intended methods. Triangulation involved the capturing of multiple perspectives/participants (i.e., female and male veterans, participants with diverse service experiences, etc.) and using multiple sources (i.e. observation, documentation, interviews, etc.), to gain diverse perspectives and insight provided during the data analysis process (Morrow, 2005). By gathering data from a variety of participants through a variety of strategies over an extended period of time (i.e., during recruitment, throughout the 4-day river trip, and one month after the trip), the findings produced by the research process were considered more trustworthy than if, for example, data had only been gathered from a single participant through a single interview at one point in time (Morrow & Smith, 2000). When using this constructivist paradigm, researcher reflexivity becomes tremendously important to gain a better understanding of how the researcher’s perspective, opinions, assumptions, biases, and experiences have influenced the research and the overall findings. For this study, I kept a reflective journal, chronicling my assumptions, biases, reactions, and experiences that may have influenced data gathering and interpretation. Content from this reflective process has been incorporated into the presentation of the data itself. In addition to trustworthiness, certain ethical considerations came into play during the research process. For example, there were evident differences regarding the researcher’s level of education compared to the participants’, which may have contributed to relational barriers between myself and the participants. A potential ethical 75 concern was the possible exploitation of individual privilege to extract information that, in the absence of such a power dynamic, participants would not feel obligated or willing to provide. Researchers often represent a position of authority, which was taken into consideration during the more nuanced moments of the research process through emphasizing the voluntary nature of research participation and continual reminders that the disclosure of personal information was entirely optional. Veterans tend to be disproportionately male, so, as a woman, I undoubtedly received a version of information from the participants that was influenced by their gender norms, beliefs, and opinions regarding women. Similarly, as a woman, I gave myself the freedom to set clear boundaries in my interactions with the participants in order to feel safe and comfortable. Therefore, my gender identity and expression influenced both the data gathering and analysis process. Additionally, researcher and participant differences existed regarding experience levels and general comfort within nature-based recreation settings. For example, I had a moderate amount of river rafting experience, as well as extensive experience in landbased multiday wilderness settings. Furthermore, I was in very good health and felt physically prepared to engage in a challenging recreation environment. Not all of the participants, however, felt the same level of comfort in a river trip setting. Most of them did not have any experience with river rafting, water-based recreation, or multiday wilderness recreation experiences. Many of them, however, enjoyed hunting and/or had spent a substantial amount of time in camp-like circumstances during their military service. Some of the participants, however, experienced a base level of discomfort in the outdoor setting that exceeded the researcher’s level of discomfort. This might have 76 impacted their sense of confidence while engaging in the social environment, involvement in group dynamics, and/or self-disclosure regarding the challenges and positive experiences they encountered during the trip. Overall, these individual differences were taken into consideration throughout the research study to ensure ethical practices from start to finish. 3.5 Results The research participants included eight veterans with PTSD, three women and five men. Five identified as White and not Spanish/Hispanic/Latino; two identified as White and Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, or other Spanish/Hispanic/Latino; and one identified as American Indian or Alaska Native. Three participants were 23-33 years old, four were 34-45 years old, and one was 46-54 years old. All of the participants identified as heterosexual or straight; three were dating, engaged, or in a committed relationship; four were married; one participant was separated or divorced; and all but one of the participants had children. It is also worth noting that two of the participants, a woman and a man, were in a committed relationship with each other before, throughout, and following the river trip. The themes, definitions, and thematic categories representing the social environment that emerged during the river rafting trip are presented in Table 3.5. 3.5.1 Contrast with Home Life One of the most prevalent qualitative findings was the degree to which the social environment on the river trip contrasted with the participants’ everyday lives. Multiple 77 Table 3.5 Themes Theme Definition Categories Contrast with Home Life Relaxed enough to socialize, less distracted & more present helpful guides, refreshing setting change, sense of freedom, less judgment & misunderstanding, more interaction & less isolation. Removal from and contrast with everyday thoughts, feelings, relationships, and duties significantly impacted the social environment that emerged. Activities Activities during the river trip, such as hiking, kayaking, Unforced conversation, increased camaraderie, opportunities to help each other, education and interpretation from the guides, and playing games at and unstructured free time. camp, contributed to the social environment that emerged. Commonalities Shared identities, values, and Veteran identity, mental health issues, outdoor experiences profoundly contributed to the social interests, and irrelevant differences. environment that emerged. Group Dynamics Group engagement, positivity, informed by service experience, informed by personal characteristics, no cliques, no conflict, helpfulness, laughter, natural trust & openness, and family-like. Individual Changes Anxiety reduction; optimism about future trips; improved empathy, patience, & mood; more time in nature; reboot & reset; personal reflection through social comparison; confidence in uncertainty; taking responsibility & initiative; and coping. River Trip Relationship Outcomes Resource sharing, social support, intent to stay in touch, did not stay in touch, proximity facilitated connection, and observing suffering. This particular trip involved certain group dynamics that would not necessarily be replicated on other trips. Participants identified specific ways the trip individually impacted them, both during and after the trip. Participants identified specific outcomes of the social group that formed during the river trip, both anticipated and realized. 78 Table 3.5 Continued Theme Definition Categories Everyday Relationship Outcomes Improved family relationships, family members noticed changes, started dating, reevaluated friendships, more volunteer work, engaged in public spaces, comfort in crowds, and less social anxiety. Ideal River Trip 8-12 people, prefer only veterans, okay with family, prefer only strangers, this trip was ideal. The river trip impacted participants' primary and secondary relationships in their everyday home life. Participants discussed the qualities of what they perceive as an ideal social environment on a river trip. 79 veterans discussed how anxious and stressed they tend to feel as they go about their daily routines, which often function as an impediment to the development and maintenance of a quality social life. On the river, however, they began to feel relaxed enough to socialize. For example, when asked about how their everyday social experiences compared to their social experiences on the river, the veterans all expressed the same feeling of being much calmer and comfortable when socializing on the river trip. Participants said, “[The outdoor setting] calms me down,” “it’s more comfortable here,” and “this is great in comparison to being at home.” The outdoor environment, in particular, was identified as a primary contributing factor toward decreased anxiety and increased social comfort. For example, one participant mentioned that, “I think being in the outdoors allowed [us] to open up a little bit more and probably not be as reserved.” This same sentiment was echoed by another veteran who said that being in an outdoor environment, “makes me kind of come out of my shell a little bit more.” One of the more reserved participants described the social impact of the outdoor environment well when she said: [Being in an outdoor environment] takes away all the stress that I've had and all these stuff in my head that I had going on and come out here and relax, and I just feel comfortable and calm and peaceful and want to talk with people now. Beforehand, with all that stuff going on, I don't want to talk to anybody. Now I'm just like, ‘Oh.’ This is kind of the quickest I've opened up ever. In addition to feeling less stressed, many of the veterans expressed that the river trip setting helps them to feel less distracted and more present in the moment. One of the veterans recognized that in his current social circumstances, he tends to be highly 80 distractible and unfocused, which he said contrasted starkly with the social environment he experienced on the river trip: I'm a full-time college student and… just being in the halls and you can talk with people and stuff… there's tons of distractions, you know? You can't really be in the moment. Or I can't be in the moment so much just because I have a bunch of distractions, things like that. But out here you can see everything… And I can just be [here]. Another veteran mentioned his everyday social context causes him to experience distracting thoughts and memories that make it difficult for him to focus. However, he found that, in the outdoor environment, “[you] don't have those distractions that continuously remind you of things you're not trying to think about.” The absence of mobile personal devices on the river trip was also identified as a factor that reduced distractedness within the overall social context. For example, one veteran repeatedly expressed an appreciation for the fact that “people aren't on their phones when you're talking to them.” When asked about how the social environment on the river trip compared to their everyday social life, one veteran simply noted that during the river trip, “nobody's buried nose in their phone.” The presence of skilled, helpful guides who took care of daily functional tasks and made all of the major group decisions also differed greatly from the everyday lives of the participants. One participant noted, “I don't have to worry about anything - the guides take care of the details.” Many of the veterans had partners, children, and jobs that required frequent decision-making and responsibility. During the river trip, however, they were invited to sit back and enjoy each day without having to make decisions. The river trip also provided a refreshing setting change that contrasted with participants’ everyday environment. Spending time in the outdoors not only gets people, 81 “away from the everyday life,” but also, for the participants who live in urban environments, “away from the city sounds.” Similarly, one of the participants experienced a sense of freedom during the trip that eluded them in their home life. She mentioned it often, stating, “I feel freedom here,” particularly while camping and on hikes. However, the river trip factors that differed most dramatically compared to their home life were the nature and extent of social interaction on the river trip. More specifically, participants frequently and repeatedly mentioned how much less judgment and misunderstanding they encountered during their time on the river, as well as how much more interaction and less isolation they experienced. Part of the change in judgment was internal, as one veteran noted: “[At home] I'm looking everybody up head to toe, head to toe, looking at them, scheming, you know? ... Now, this whole thing on this river... I know there's a part of me that has lessened its judgment of other people. So, that's been good.” For most of the participants, however, the lack of judgment and misunderstanding derived primarily from their perceptions of other peoples’ thoughts. One veteran said, “It was good knowing that I could just talk to anybody and feel comfortable and knowing that I wasn't going to be judged.” Another stated, “Here I'm not worried… None of that judgment stuff.” Many of the veterans particularly noted their frustration with feeling misunderstood and judged by civilians in their everyday life. On the river, however, all of the participants expressed a strong sense of shared understanding, as well as enhanced freedom to act without fear of judgment. In addition to the nature of the social environment, the sheer amount of social interaction contrasted dramatically with nearly every participant’s home life. One of the 82 veterans was employed in a position that facilitated extensive, frequent social interaction, but the remaining seven participants identified their everyday social life as largely “nonexistent.” In describing their typical social experiences, participants said, “I don’t socialize at home,” “I don’t have much of a social life,” and, “I never leave the house.” The veterans seemed to greatly appreciate the way the trip essentially forced them to socialize so frequently and extensively. When discussing what he appreciated about the trip, one participant said, “Being on this trip has forced me to do something that I would have not done at home: socialize with others.” Some even viewed the trip as a valuable opportunity to overcome their fears and aversions to socializing, as well as a chance to rediscover their social abilities. One participant expressed the positive sentiment well when he said, “Coming here, you're forced to socialize, but then you realize it's not that bad.” Another veteran said that becoming more comfortable in the highly social river trip environment, “makes me realize, ‘hey, you can still socialize.’” 3.5.2 Activities Certain river trip activities, such as hiking, kayaking, playing games, and setting up camp, as well as interpretation and education provided by the guides, stood out as important contributors to the creation of the social environment that emerged during the river trip. Activities seemed to facilitate unforced conversation and allowed for increased camaraderie. During 1 of the days, the amount of time on the river was far shorter than other days, traveling only 4 miles instead of 10-20, allowing for additional time at camp to participate in various activities. One of the veterans recognized the extra time at camp for engaging in shared activities as useful for building camaraderie, stating, “I think that 83 was a very good day to do 4 miles, because it forced us to be back at camp where we're all together, playing games, bonding, talking, sharing stories.” Another participant identified the activities as a valuable context for having opportunities to help each other, stating, “When we're in the outdoor environment like this doing activities, we help each other out.” Another expressed a similar sentiment, particularly regarding the value of setting up camp and exploring the outdoors together, when he said, “being able to explore [nature] with each other… [and] we help each other put everything up and take everything down.” Throughout the trip, some of the veterans kept coming back to this idea of finding value in being given the opportunity to meaningfully contribute, particularly to the veteran community, instead of being the ones receiving help. While the activities were useful for naturally cultivating a quality social environment, the veterans emphasized not having an interest in required, officially facilitated activities provided by the staff. Instead, they emphasized the value of unstructured free time for providing an enjoyable river trip. One participant expressed her appreciation for this feature of the trip when she said, “I feel freedom here, and I can socialize whenever I want or don't want.” Another veteran also expressed his interest in not having highly structured or facilitated activities: Everybody's playing cards. And you know the good thing is, this is not a forced counseling situation. This is naturally developed. People just want to hear their stories… I think this whole trip is team building. You know what I mean? It's like you got to get the gear out. You got to do this; you got to do all this stuff. And it's not like, “Okay, we're going to land here on this beach today and have a team building exercise.” No. This whole damn trip is a team building exercise, you know? 84 Overall, it seems the nature of the trip itself allows for the activities that people engage in during unstructured free time to promote unforced conversation, camaraderie, and mutual support. 3.5.3 Commonalities One of the most salient themes was the importance of being on the trip with people who had certain shared identities, values, and experiences. The three commonalities that emerged as highly relevant included having a shared veteran identity, dealing with similar mental health issues, and having similar outdoor interests. First and foremost, each participant repeatedly emphasized the essential importance of having the opportunity to participate in veterans-only trips and the many ways having a common veteran identity contributed to the social environment that emerged during the trip. Even though the researcher was a civilian, the participants freely and generously shared about the many ways that having a shared veteran identity influences social dynamics. For example, one participant said, “I trust veterans a whole lot more… we’ve been through more training.” Others said that the sense of trust comes from an understanding that, around fellow veterans, they can be themselves and do not have to watch what they say. One of the veterans provided a clear description of how the preexisting trust that veterans share contributes to an accelerated process of bonding and building camaraderie: We all share one common thing that we served… we signed up, and we served… [it] creates an instant bond. The bonding and the socialization is almost already there… it takes us less time to get to know each other and start talking, communicating, without stepping on anybody’s toes, because we all know that we’re Veterans, we all know what we’ve done, there’s no line that you’re worried about crossing… a lot of civilians don’t understand that… they don’t know how 85 to handle it sometimes. You get around a bunch of civilians and you start telling stories like we do, people’s jaws drop like, ‘oh my god.’ Or ‘that’s inappropriate.’ No. It’s normal. To us, it’s normal. It’s good to be around other people that you can act like yourself and they understand exactly where you’re coming from. Another participant shared about how different, and frustrating, it would have been to have civilians on the river trip: [Nonveterans are] going to spend more time in their head worried about if something would trigger us… a trip like this should be relaxing, not for us to be educating someone else… you hear half the stories and stuff and the language that gets used and stuff like that. Some people they would be, ‘oh my god. I paid for this trip, or whatever, and I’m on this trip, but I’m with these people, and I’ve got to listen to this.’ I think that’s just the military culture… this is a total no judgment zone; you know what I mean? Other group members consistently expressed a similar sentiment, stating that, “I wouldn’t be saying next to anything with civilians around… I wouldn’t want to share anything.” One of the more reserved group members summarized the relevance of a shared veteran identity when she said, “it’s something we all have in common. We all kind of understand each other and know what the other is talking about. We don’t have to ask questions… you’re able to be yourself and not hide who you are.” A secondary commonality that most of the participants expressed as a relevant contributor to the social environment on the trip was having similar mental health issues. For example, one of the participants noted that “Any veterans that suffer from PTSD, depression, anxiety, stress, I think would feel more comfortable around other veterans that may have shared similar experiences in the military.” Another put it succinctly when she said, “our symptoms and our hurts are the same.” For example, after a long day of rafting, and when everyone was sitting around at the campsite, one of the veterans started talking about his history of having suicidal thoughts. He expressed what a relief it was to be able to talk openly about that part of his life with people who understood that type of 86 experience and would not “freak out” or judge him for it. Others nodded understanding and agreed with him. In a civilian setting, group members might have grown uncomfortable or concerned, but within a context of people who have such similar mental health experiences, not a single person appeared uncomfortable or distressed by his comments, and the conversation flowed seamlessly to the next topic. Simply put, one of the veterans said, “we all have similar stories, similar experiences, and similar issues that we’re trying to overcome while we’re here. Just makes it easier.” A few of the participants mentioned that their sense of social comfort on the river trip was enhanced by group members having a shared interest in outdoor recreation activities. Expressing his appreciation for this commonality, one veteran said, “It seems that everybody has a common interest being outdoors, camping, rafting… everybody sharing that common interest, as well as being Veterans on top of it, just makes it even better.” Another veteran agreed with him, expressing that “we all like to be outside” and how that common value contributes to a stronger sense of understanding and a shared enjoyment of the river trip. When specifically asked about whether or not certain demographic factors, such as age, rank, gender, education, and/or ability status, influenced the social dynamics of the trip, nearly all of the participants kept coming back to the idea that these were irrelevant differences and nothing mattered except for military service. Even the nature of one’s service experience, whether it involved combat, deployment, or a particular branch of the military, was regarded by most as extraneous. Rank stood out as particularly insignificant, with participants universally agreeing that it did not matter, stating decisively, “the only thing… was we all wore a uniform. Rank had nothing to do with it.” 87 One of the participants felt that international service was significant concerning the group dynamic, stating that, “I think if you've served overseas, like considered overseas veteran regardless of rank, enlisted or officer, I don't think that matters just as long as you served overseas.” Others, however, said that as long as a person had served in the military, the nature of the service experience was an irrelevant component of the social dynamic. Most of the participants, when asked directly, claimed that gender was not important. One veteran even explicitly mentioned, “I like that our group is composed of both men and women.” In the interviews and journaling, men were particularly adamant that gender did not matter. The women tended to agree, but some of them would make casual comments and ask questions that indicated otherwise. For example, two of the female participants asked about the gender composition of the trip before they agreed to participate. Also, one of the women commented specifically about women, saying, “the females I feel they are sisters and feel trusting of them.” Additionally, during one of the interviews, a female participant said that gender did not matter but then went on to talk about how previously she would have been uncomfortable being on a trip with so many men, but that, at this point in her life, being on a river trip with men has actually been a constructive experience for her: It was really good to be around certain males on a mix group because when they let down their barrier and they become vulnerable then it makes me want to just open the flood gates, like okay he just shared something with me that he probably wouldn't of shared with anybody outside of this so that's really cool. That help me open up a lot. Immediately after making that comment, however, she retracted her statement, saying, “I will take that back, it's all veterans just getting through life.” 88 Furthermore, despite participants’ general tendencies to promote the irrelevance of gender, data from the social network analysis, represented in Figure 3.1, seemed to demonstrate that gender did influence the social dynamics, at least regarding primary relational preferences. When asked who from the trip they would want on a theoretical future river trip, all but one of the women listed at least one male participant. Four of the five men, however, only listed male group members. The only man who listed women was the person who was actively in a committed relationship with a woman who was on the trip. Furthermore, at one point, one of the male participants said, “female veterans are often hard to talk to.” Also, based on participant behaviors regarding who they chose to ride in boats with and who they primarily conversed with at the campsites, with the exception of the preexisting couple, male participants seemed to demonstrate a clear preference for spending time with the men in the group. The women, however, tended to float among group members without clear or explicit regard for gender. Everyone did seem to get along quite well, but there did appear to be at least a mild preference among to men to converse primarily with fellow male group members. Therefore, it seems gender did influence the social dynamics that developed, at least to some degree, even though the majority of participants did not personally perceive it to be important. Ultimately, however, the shared experience of military service and common struggles with mental health brought the group together in a powerful way, far beyond the influence of any superficial qualities may have amplified their differences. Figure 3.1 Social network analysis 89 90 3.5.4 Group Dynamics After participating in multiple river trips with veterans, one becomes keenly familiar with the reality that not every trip is the same. Each trip has its particular strengths, weaknesses, and unique qualities. Multiple participants on this trip had been on similar trips before, though not with each other. Consequently, they were able to provide valuable insight regarding the unique qualities of this particular trip that would not necessarily be replicated on other trips. First, participants noted that there was an exceptionally high level of group engagement during this trip. As one participant noticed, “There's nobody sitting back like, 'Eh, I don't want to do that.' Everybody's fully involved.” All of the participants seemed to be willingly engaged in all of the different components of the trip. One veteran described the dynamic well when he said, “I haven't seen anybody try to remove themselves from the group or anything like that.” Not only was everyone fully engaged, but there was also a strong sense of positivity throughout the group. Opportunities to complain were certainly available, but the participants all had a positive outlook and focused on what was good about the trip. One of the participants recognized this tendency when he said, “everyone had a great personality and a great outlook on things.” It also seemed that the way the veterans socially engaged with the group was informed by service experiences. For example, one of the participants remarked that his position of leadership in the military taught him how to speak up in group settings, so he felt fairly comfortable expressing his opinion and interacting with group members: I'm not really afraid to talk to anybody. I mean, I was a staff sergeant. I had to get up and talk in front of people all the time. So I don't have a problem going up and 91 talking with people and stuff like that. So yeah, my background, yeah, does. And I'm used to managing people, so that too as well. That helps out. Another veteran, however, said that his service experience, in combination with other factors, tended to have the opposite effect when he said, “I think my life experiences, being a medic and then being a police officer, detective, probably combined with PTSD, stress, anxiety, now make me kind of sit back and not be as open and outgoing.” Others felt that their social experiences on the trip were informed by personal characteristics, such as age and religion. One of the participants stated, “I'm a Christian, and I just like ... To me, everyone deserves a chance... Don't judge by a cover; just give everyone an opportunity.” Also, even though most group members said that age did not matter to them, the eldest veteran mentioned, “I can probably guarantee you I'm the oldest one here… there was a brief period of time when I felt left out because of my age.” Aside from these two examples, veterans largely stated that personal characteristics were irrelevant and that being a veteran was all that mattered when it came to the social dynamic. Two rather unique components of the group dynamic that all of the participants identified were that there were no cliques and no conflict. Anyone who has gone on a multiday river trip knows that conflict, or even just a minor disagreement, usually occurs at some point during the process. However, the members of this particular group all got along really well and did not seem to fight at all. One of the veterans identified the uniqueness of this experience, stating, “We never argued, like the entire trip.” Group members also tend to parse off into smaller, somewhat exclusive subgroups during outdoor adventure trips of this nature, which many of the veterans recognized from previous trips they had attended. During this trip, however, everyone seemed to get along 92 well with each other and were continuously ready and willing to socialize with all of the group members. A veteran summarized it well when she said, “Other trips I've been on, it's just there's drama or fighting and just people picking on others and cliquing up. And out here, it's just everyone gets along and talks to everyone, so it's good.” The group members recognized that they would not expect a similar conflict- and clique-free dynamic to be replicated on other trips. There was also a strong propensity toward helpfulness within the group dynamic. As one veteran noted, “Everyone is… so ready to do something and get out there and 'I'll do that' and ready to help.” The helpfulness was oriented toward serving fellow veterans, as one participant said, “I felt a kinship to the group, not only because we are vets but because it seems to me they all are in some way advancing their life to be able to help more vets.” There was a constructive eagerness to help and support each other throughout the trip. A veteran articulated this unique component of the group dynamic well when he said about the group, “they’re not takers, they’re actually givers.” During these trips, it is not uncommon for there to be at least one group member who sits back and expects everyone else to do the work for them. Within this group, however, everyone was ready and willing to assist, often long before it was overtly requested. Plentiful laughter was another salient component of the group dynamic, particularly when playing games and socializing at the campsites. As one of the participants wrote, “The card game was a great time to have the best medicine, laughter.” For participants with a history of substance abuse, the amount of laughter and joy was particularly noteworthy. As one participant stated, “Sitting at the table and playing cards was the most fun and laughter I have had sober in over a year.” 93 While the dynamic of bonding over a shared veteran identity certainly seemed to play a role in overall group cohesion, even still, this particular group seemed to develop a natural trust and openness with each other very quickly. One of the more reserved group members who had been on other veteran trips recognized the uniqueness of the situation, stating, “This is kind of the quickest I've opened up ever.” Another veteran expressed a similar sentiment, stating, “I feel like we already trust each other.” Eventually, a familylike dynamic developed among the river trip participants. As one of the veterans stated, “These are like non-blood brothers and sisters. It’s family, but it’s not.” Many of the participants attributed this type of bonding to the fact that it was a trip specifically for veterans and that everyone aside from one staff member and three river guides was a veteran. 3.5.5 Individual Changes The river trip participants all identified specific ways that the river trip impacted them as an individual, both during and after the trip. Some of the changes were perceived by the participants to have been sustained over time, but some were only specific to the river trip setting. The first change that the participants tended to notice was substantial anxiety reduction. Everyone who attended the trip traveled from out of town to participate, and all but two of the people had never met each other before, so many of them felt more anxious than usual leading up to the trip. However, anxiety slowly began to reduce once everyone met each other and got settled. A veteran articulated the phenomenon well when he said, “Anytime you go into something new there's gonna be anxiety in not knowing. I think once everybody was together and there was some 94 logistics laid out, then everybody became aware of what to kind of expect rather than just not knowing.” The presence of fellow veterans seemed particularly relieving for some of the participants, as one of the veterans described when he said, “I think a lot of us have anxiety on just going somewhere new, being around other people. But, then once we get there and it's other veterans, people start opening up it's just really easy.” With each additional day of the trip, and as participants grew closer, anxiety levels seemed to continue dropping until they were below pretrip levels. Anxiety eventually dropped so low for some of the veterans that they started to feel a renewed sense of optimism about future trips. One of the participants said: I've gone on other veterans' trips, going hunting and stuff. There's always that tinge of anxiety that comes from meeting new people, especially going on a trip where ... I've never whitewater rafted, so now I gotta meet new people, and I gotta go out on a river and do something I've never done before. It went so well that if I were to participate in other trips, I would have less anxiety about it and more of an excitement and a curiosity and interest as to how it's going to go. During the month after the trip, many of the participants identified meaningful changes in their feelings, including improved empathy, patience, and mood. When asked about how their relationships might have changed after the trip, the influence seemed to be overwhelmingly positive with veterans saying, “I think it’s helped me be a little bit more empathetic,” “I’ve been much more patient than normal,” and “I've been in a better mood.” One of the veterans found that changes in her feelings were particularly evident within family relationships, stating that, “with my daughter, and my parents, I have become a little more patient with them. The trip definitely taught me a lot about patience… just being patient and not rushing anything.” 95 Regarding their leisure behavior, the veterans claimed that the trip prompted them to start spending more time in nature. A veteran who lives on a ranch described this change when he said, “I've got a nice deck… it overlooks my barn… I never really sat out there and just appreciated it, but since I've been back, there's been multiple times where I might be out there for a couple hours.” Another veteran expressed a similar response to the trip, saying, “It makes me want to get out more.” For some of the participants, they did not necessarily think that their amount of leisure behavior changed, but a mental shift had taken place that encouraged them to consider ways of choosing nature-based options over more structural or built leisure options. One of the veterans described this shift when he said, “Not just get out and do stuff, but get out and do stuff that's more in tune with nonsocietal stuff, like not going to a mall, not going to a restaurant, rather, going down to the creek or going out to the woods, or down to the river.” One of the participants expressed a similar cognitive shift when she said, “I used to freak out if I didn't go one day to the gym. But now it's like, I feel like I don't need to go to the gym, and I just want to be outdoors… I don’t even want to go back to the gym because it’s just so artificial.” Many of the participants identified that the experience served as a much-needed way to reboot and reset their life. During the trip, one of the veterans said, “I kind of feel reenergized and relaxed, which I haven’t felt in a long time.” Another participant said the trip had a similar effect once they returned home, saying, “I came back with a lot of weight off my shoulders. Like I was actually able to catch my breath.” For many of the veterans, the river trip was like refreshing a website browser, where the essential structure and content of their lives were the same, but they were able to view it in a new, 96 fresh way. For a few of the group members, the social environment during the trip allowed them to engage in personal reflection through social comparison. For some of the participants, comparing themselves to fellow veterans during the trip gave them motivation to make changes in their own life, stating that, “after going on that trip, seeing where everybody else is at in their life, I'm like, I want to be somewhere else in my life as well.” For others, it allowed them to recognize how far they had come in their healing process: When I would listen to some of the others, and they were kind of saying some of the negative things about their issues, I can really reflected and be like, “Okay, I remember being there at that point,” and kind of just seeing even my own progress. Like, obviously not downing them, but just saying, “Man, I'm actually glad that I've actually made some serious progress.” For others, social comparison allowed them to reflect on the whole healing process and put their own recovery in perspective, as one veteran recognized when he said, “It feels like there’s different levels of the healing process… coming to these retreats reminds me of that.” Increased confidence in uncertainty was another frequent change within the individuals who participated in the river trip. Many of the veterans felt anxious in anticipation of the trip but ultimately had a gratifying experience. For one of the veterans, having such a positive river trip experience, “provided me with some reassurance that it's okay to step outside the comfort zone.” Others saw it as fuel to demonstrate confidence in future comparable scenarios, stating that, “It almost makes me feel like I can maybe just go ahead and commit to something without sitting and freaking out about it.” For others, the river trip was a catalyst for taking responsibility and initiative in 97 their life. One of the participants mentioned how it influenced the initiative she takes with domestic tasks, saying, “I feel like I’m doing a lot more around the house.” Another veteran said the trip caused him to take greater responsibility for his health-related duties. He said the trip encouraged him to, “Get back in the program, the VA, get some medical shit done that should have been done. Getting back to taking care of myself a little bit better.” One of the more striking findings what that the trip made it possible for one of the veterans to be more successful at coping with difficulties related to their mental health. This particular veteran has a persistent mental health condition that causes cyclical major mood swings. However, they felt that the trip significantly shortened the length of a depressive swing they experienced after the trip: I've got bipolar, and I was like if it gets to be too much, it can grow into a depressive swing. I started getting there, and I was ready for it to happen, but it wasn't nearly as bad as what it would have been… It was much shorter. I was able to stop the swing before it went full tilt.” Throughout a conversation after the trip, this veteran expressed how unique it was to feel like they were able to bring themselves out of the depressive swing much more quickly than they typically can. While it was not evident whether or not this improvement in coping persisted beyond 1 month after the trip, it did seem to produce immediate benefits. 3.5.6 River Trip Relationship Outcomes Throughout the river trip, the participants referred to various outcomes of the social group that formed. Most of those relational outcomes were anticipated but never came to fruition, but some of the outcomes were eventually realized. For example, from the very 1st day together, the veterans discussed resource sharing opportunities that the 98 trip could provide. Many of the veterans have been on other veteran-specific nature-based outings and were eager to share about these opportunities. Some of the veterans said they would send the staff a list of the veteran-specific resources they knew of so that the research team could create a master list to share with everyone, which a veteran affirmed the potential value of when he said, “We all have our own resources and combining those together creates resources for others.” Comments were made that reaffirmed their appreciation for resource sharing, such as, “each [veteran] is full of resources,” and, “[the other veterans] know about programs that I’ve never heard of before.” Ultimately, however, the only resources that were shared were those that were mentioned during the trip itself. Similarly, group members anticipated that increased social support could be a potential benefit of the social group that formed during the trip and expressed an intent to stay in touch. They stated that “you’re adding to your tribe,” and “there could be benefits as far as having another person in your support structure.” When asked if they expected to stay in contact with the group members after the trip, the response was unanimously affirmative. One month after the trip, however, they largely did not stay in touch. The only group members who were still in contact with each other, beyond passive social media connections, were the people who were in a committed relationship and two of the male participants. It seemed that proximity facilitated connection because those who remained connected were the ones who lived near each other. Most of the veterans did not identify any potential drawbacks of staying in touch with each other, but a few did identify observing suffering as the worst possible outcome of maintaining communication with each other. One of the veterans articulated this 99 sentiment well when he said: “The only drawback is when someone quits being a work in progress, and to watch that happen to someone that you made a bond with.” Another veteran recognized a more severe potential scenario, saying, “God forbid the worst thing is that they commit suicide, and you got to live with that.” For the most part, however, the group members felt that staying in touch would primarily have a positive influence on each others’ lives, though few actually did. 3.5.7 Everyday Relationship Outcomes Brief stress relief and having newly formed loose connections with people who live far away were outcomes that certainly had value, but arguably the most profound and vital impact was the way the river trip influenced participants’ existing everyday relationships. First and foremost, participants stated that the river trip improved family relationships and that their family members noticed changes in the veterans. One of the veterans spoke about how often his family members tend to worry about him and how both participation in the trip and personal outcomes of the trip reduced their concerns: I know that my dad has been worried about me… but when I got back, I had to go down to his house… I explained to him what [the trip] was. And what we did and what we talked about. Kind of about what the program… and I explained to him how I got some more resources I can look into. So that made him happy. And then… I went over [to my sister’s] house and explained it, and by then I had some of the pictures… So it did impact my family. It made them feel better and not ... They worry about me. There's been times where I really didn't take care of myself. I think this [trip] made him feel better. Get back in the program, the VA, get some medical shit done that should have been done. Getting back to taking care of myself a little bit better, I guess. While some of the participants mentioned changes in their relationships with their parents, others recognized how the trip seemed to positively influence their marital relationships. One of the veterans noted that “My wife says that I’ve been in a better 100 mood. I’ll take her word for it. She says it feels like we’re… not that we were fighting a lot before, but she feels like it’s even better than it was now and that we’re getting along better and that I’m a little more relaxed and opened up.” Another participant recognized ways in which the trip had a positive influence on her approach to parenting, saying that the river trip experience, “made me feel better about spending more time with my daughter, making her number one, but instead of just talking the talk, walking the walk.” Additionally, one of the veterans said that the river trip was a catalyst for him to start dating again for the first time in a while, saying, “I haven’t dated in about a year and a half now. But now I’m actually actively dating.” Others recognized that the trip encouraged them to reevaluate friendships, more seriously considering what they actually wanted and creating firmer boundaries with people who they perceived to have a negative influence on their life. One of the veterans saw it as, “an opportunity to evaluate [toxic people] in your life,” while another said that the river trip, “helped me sit and reevaluate what I actually wanted [in my relationships].” Others found that the trip impacted relationships within the context of social spaces outside of their immediate social circle. For example, a few of the veterans said the trip prompted them to engage in more volunteer work, particularly within the veteran community. One of the veterans, who had expressed an interest during the river trip in becoming more actively engaged in volunteer work within her local community, said, “I kinda came back, and I decided to get out more and I have been volunteering with a couple of organizations.” The two veterans who were in a committed relationship volunteered for an event that provides services to homeless veterans soon after they returned from the river. The female partner described the significance of that experience 101 when she said, “it was cool to feel like you're giving back, like we just got pampered, pampered as in our souls with the river, and with the river guides, and they just took care of us. And then it was cool to full circle take care of these homeless veterans. That was really neat.” Most of the participants expressed how the river trip caused them to become more engaged in public spaces within their local community. One of the veterans provided a meaningful example of how this played out in his own life when he said, “We've got a general store down here where the old people hang out. You go down there in the morning; they're all sitting there drinking coffee. I go in there with my veteran's hat on and hello. Now they know me because I started talking to them.” Previously, he had expressed that he used to keep his head down and try to avoid people when he would go to the general store, but after the trip, he demonstrated an intentional effort to make himself more approachable for the people in his community. Similarly, one of the younger veterans found himself taking greater advantage of social opportunities at the gym. He mentioned that, before the trip, he would try to avoid conversations with people at the gym. After the river trip, however, he said, “I am actually talking to a few more people at the gym.” After participating in the river trip, many veterans expressed that they felt more comfortable in crowds than they were before the trip. For example, one of the veterans said, “I used to really not like crowds… [now] I'm a lot more willing that if somebody says, 'Hey, you wanna go do this or that?' I'll go now.” Others talked about ways that their leisure behavior had changed through participation in the river trip, noting a new willingness to participate in inherently crowded activities, such as sporting events and 102 festivals. Overall, most of the participants said the trip caused them to experience less social anxiety during their everyday life. One participant noted that “Normally I would avoid talking to people. I would just look at my phone or whatever I needed was, and just go get it. But now I interact with people.” Another claimed that the trip “made me more relaxed around other people.” 3.5.8 Ideal River Trip Finally, the participants discussed what an ideal social environment on a river trip would involve. Everyone agreed that a small group of 8-12 people would be best. Some said, “8 to 10 people is perfect,” while others expressed a similar sentiment, noting that, “10 I think would be good. Maybe 12. But 10 I think would be good.” One of the participants provided further information regarding why it is crucial to keep the group small, stating that, “We also are the type of people that are interested in small groups. Because it's easier to bond and communicate, and the more people that start being around, it gets a little sketchy for us.” While group size was agreed upon by the veterans, other social demographic preferences differed somewhat from person to person. For example, many of the participants said they would prefer only veterans on a trip, saying that, “It does make it more ideal to have just the veterans around most of the time so that we can be who we are without offending.” Others, however, said that they were okay with family attending a river trip, stating that, “I wouldn’t mind going with family,” and, “I would like my wife to come out.” One of the veterans, however, clearly expressed that they would not want 103 family members on the trip because, “When you start involving family members, they're still civilians, so even though they have a veteran as a spouse or a parent, they still can get touchy about stuff.” Similarly, another veteran said they would prefer only strangers on a trip like this, claiming that it would be better, “having individuals with no one that they’ve prior known.” In the end, everyone on the trip seemed to share the sentiment that this group was ideal. Various comments were made reinforcing this belief, such as, “I think this right here is perfect,” and, “this trip, it’s been perfect from the start.” When asked what their ideal trip would look like, one of the veterans said, “You’re seeing it right now.” Given the previously mentioned group dynamics, particularly regarding the lack of conflict, lack of cliques, and level of positivity and engagement of group members on this trip, I found this sentiment unsurprising, but unique. 3.6 Discussion The findings of this qualitative study are consistent with existing research regarding the social benefits that nature-based recreation experiences (Bennett, Van Puymbroeck, Piatt, Rydell, 2014; Caddick, Smith, & Phoenix, 2015; Lundberg, Taniguchi, McGovern, & Smith, 2016) and particularly river trips (C. L. Anderson, Monroy, & Keltner, 2018; Dustin, Bricker, Arave, Wall, & Wendt, 2011; Scherer et al., 2014) tend to provide veterans. However, the findings also seem to indicate that the lasting social benefits extend beyond the relationships that form during the trip itself (Rogers et al., 2016) and are particularly impactful within the participants’ everyday social life. Given the critical importance of having a strong everyday social support 104 network for people with PTSD (Herman, 2015), particularly regarding the reduction and prevention of symptoms (Kaniasty & Norris, 2008), these findings indicate that river rafting trips have the potential to produce valuable health benefits for participants. Many of the qualitative findings here are particularly relevant in light of what we already know about PTSD and the way it can influence an individual’s neurological activity and social experiences. For example, PTSD involves the overactivation of the amygdala and suppression of the prefrontal cortex, which can make decision-making and problem-solving particularly difficult (Psychiatry Neuroimaging Laboratory, 2014). Therefore, having river guides who provide relief from the mental strain of constant decision making offers an opportunity for cognitive relief that the veterans might not get to enjoy in their daily life and perhaps need more than the average person. The participants’ appreciation for unstructured free time where they do not have to make decisions, or complete tasks might also be a byproduct of the disproportionate cognitive strain PTSD produces in their day-to-day experiences. Getting to enjoy a social context that places minimal demands on their prefrontal cortex seems to be particularly relevant for this population. Similarly, difficulty with concentration is known to be a common PTSD symptom (APA, 2013) resulting from reduced activity in the prefrontal cortex (Psychiatry Neuroimaging Laboratory, 2014). Participants found they were able to be less distracted and more focused during the trip, which may indicate that the environmental context the river trip provided was in some way beneficial for reducing cognitive strain and increasing higher neural functioning related to attention. Existing studies on attention restoration theory indicate that “natural environments are ideal places to restore 105 diminished attentional capacity” (Basu, Duvall, & Kaplan, 2018, p. 2). Therefore, this qualitative finding aligns with current research. Many of the veterans who came from urban settings expressed that the river trip provided a reprieve from the emotional and physical strain that the noise and sounds of an urban environment frequently place on them. Existing research confirms that noisy environments, such as those that often permeate dense urban settings, can produce an exaggerated startle response and other forms of physiological reactivity in people with PTSD (APA, 2013). Continually enduring such symptoms can inhibit social functioning (Herman, 2015), so river trips of this nature may provide a useful environment for reducing physiological reactivity for individuals who live in urban environments and, subsequently, improving an individual’s capacity to engage with the social group effectively. Also, the findings from this trip indicated that river trips might have potential value for improving the health and wellbeing of the veterans with PTSD who participate. For example, participants expressed that they experienced improvements in coping after the trip, reduced anxiety as the trip progressed, and less social anxiety after the trip. These river trips, or nature-based recreation experiences more generally, may have potential value for improving the health and wellbeing of veterans with mental health conditions, particularly regarding anxiety and coping. However, without additional research, such claims cannot be confidently made or applied to practice. For most people with PTSD, socializing can be a highly taxing experience and, consequently, people with PTSD can develop a habit of generally avoiding social environments (van der Kolk, 2014). Social isolation is one of the key symptoms of PTSD 106 (APA, 2013), so it was not surprising that so many of the veterans described their everyday social life in such harsh terms. However, the veterans who attended the river trip saw a shift in this behavior afterward, from experiencing more interaction and less isolation, to feeling more comfortable in crowded situations and engaging more in public spaces. This may seem like a small shift, but given the critical importance of social support in reducing PTSD symptoms and promoting recovery from trauma (Charuvastra & Cloitre, 2009), and that social isolation is one of the key symptoms of PTSD (APA, 2013), this type of shift can be life-changing. These findings also align with Bronfenbrenner’s Bioecological Model of Human Development (BEM), which posits that developmental outcomes, including social development, are produced through ongoing and reciprocal interactions between a person and their contexts (Bronfenbrenner, 1994). In this study, various person characteristics, such as age, gender, inclination toward helping others, positive attitude, veteran status, and having mental health challenges, had an impact on the social context that emerged. Similarly, some of those characteristics were reciprocally influenced by the social context, such as participants’ capacity to cope with their mental health challenges, their positive attitude about future outdoor trips, and an enhanced desire to participate in more volunteer work in their everyday lives. Bronfenbrenner also presents the idea that an individual’s microsystems, which are their immediate group contexts, can influence each other, which was certainly evident in these findings. For example, one veteran expressed that his experiences in the group that he served in the military with provided him with skills that made it easier for him to take on more of a leadership role in a group of strangers. For this same participant, his 107 social experiences with the river trip microsystem empowered him to become more engaged and confident in social contexts throughout his everyday life. Overall, the way people developed socially both during and after the trip seemed to be influenced through the ongoing, reciprocal interactions between individuals and their contexts, which aligns with the propositions set forth by Bronfenbrenner’s BEM. The findings in this study also have potential implications for how river trips are facilitated by researchers, nonprofits, and/or guiding companies. For example, experiencing a family-like bond with fellow service members is not a rare occurrence within the veteran community (Junger, 2016). During these trips, the consistency and veracity with which participants expressed a preference for veterans-specific trips have important potential implications for the way veteran river trips are provided. For example, facilitators may consider limiting all nonessential civilian staff and, in so far as it is possible, only inviting participants who are veterans. One of the participants suggested that these trips would be even better if the guides, staff, and counselors were all veterans, but he recognized that a limited supply of veteran employees would make it challenging for most organizations to provide such a tailored service. In so far, as it is possible, however, people running such trips should consider the potential importance of enhancing the veterans’ experience by prioritizing veteran-only participants on comparable trips. Some of the participants, however, noted that they might enjoy different types of trips. While everyone agreed that limiting the civilian presence on such trips was essential for producing a high-quality social environment, a few people mentioned that they would enjoy having the opportunity to go on a trip with their family members and/or 108 partner. One veteran noted that they would prefer going with a group of people who all did not know each other yet, while the couple who was on the trip noted their appreciation for having someone they were close to on the trip with them and how it really enhanced their relationship. Since different veterans seem to value different group compositions for such trips, the people providing such experiences may consider the value of offering different types of trips. For example, having couples trips, or offering trips to preexisting community groups or reunions for military units, may prove socially beneficial. All of the participants on this particular trip had to have a certain level of base comfort with being on a mixed-gender trip. Consequently, people who were only comfortable with a gender-specific trip would have self-selected out of the experience. Therefore, there might be value in providing gender-specific trips, but the nature of this study prevents that information from being readily available. One of the veterans briefly mentioned that at a certain point in her life it was useful to go on a women-only trip, but that spending time in mixed company was particularly valuable for her healing and recovery process at this point in her life. Given the pervasive nature of military sexual trauma (Suris & Lind, 2008), particularly for female veterans, female-specific trips may have value. Future researchers and current practitioners may consider the social benefits of gender-exclusive nature-based experiences, but the limits of this study prevent firm conclusions about the value of such trips. A few indications about the way future trips should be optimally facilitated to enhance the social experiences and lasting social benefits of the trip seem clear and consistent through all participants. For example, the findings of this study indicated river 109 trip facilitators should restrict group sizes, capping them at 8-12 veterans per trip. In addition, given the appreciation the veterans expressed for the potential for resource sharing, trip facilitators might consider aggregating a list of resources for comparable trips and sharing this information with their veteran participants. The only people who really stayed in touch were those who lived near each other after the trip. Therefore, facilitators should consider providing regional trips that focus on people from specific areas to increase the potential for people to stay in touch and for the trip to create a support system that lasts beyond the trip itself. Nearly all of the participants also expressed an appreciation for the opportunity to demonstrate helpfulness during the trip and many increased their participation in volunteer work after the trip. Therefore, if facilitators are able to provide regionally specific trips, they might consider the benefits of pairing the trip with a posttrip service experience in the community. Veterans do tend to have a stronger cultural orientation toward service and helpfulness (Coates & Matthews, 2017), and prosocial behavior is a clear indicator of growth following a traumatic experience (Wilson, 2005), so facilitators should consider the potential value of capitalizing on veterans’ existing strengths to promote their posttrip growth and healing process. 3.7 Conclusion The purpose this case study was to gain a better understanding of veterans’ perceptions and evaluations of the social environment that emerged during a river rafting experience, as well as the potential durable social benefits that the river rafting trip provided. Through observations, interviews, written logs, and social network analysis, I 110 provided a comprehensive overview of the social group and the benefits experienced by the participants. Rigor in the methodological approach and consistency throughout planning and implementation ensured the quality of the work and validity of findings. As an instrumental case study, the overall intent was to provide data about a specific, bounded system that offered valuable information regarding a larger phenomenon – nature-based recreation experiences and their potential to cultivate social support and enhance valuable relationships for veterans with posttraumatic stress disorder. While the social network that developed was not sustained for most of the veterans, the trip was perceived as having a very positive impact on their preexisting everyday relationships. It also appears that the trip impacted them individually in fairly consistent ways, from improvements in empathy, patience, and mood, to spending more time in nature and engaging in meaningful personal reflection. Future research may consider the possibility of how frequently and extensively comparable opportunities should be provided for these social benefits to be sustained. Also, while one of the limitations of qualitative research tends to be the generalizability of findings (Creswell, 2012), these qualitative findings provide a rich understanding of the nature and development of the social environment that emerged during a river trip for veterans with posttraumatic stress disorder. CHAPTER 4 THE IMPACT OF NATURE-BASED RECREATION ON PERCEPTIONS OF SOCIAL SUPPORT FOR VETERANS WITH POSTTRAUMATIC STRESS DISORDER 4.1 Introduction Among U.S. military veterans, posttraumatic stress disorder (PTSD) is one of the most widely recognized challenges that veterans encounter as they complete their military service and adjust to civilian life (Institute of Medicine, 2012). Ongoing PTSD can contribute to a variety of complex social issues, such as marital disruption, substance abuse, social isolation, employment difficulties, and suicidal behavior (Back et al., 2012; Castro & McGurk, 2007; Dustin et al., 2016; Hoge et al., 2004; Hoge et al., 2007; Hoge et al., 2005; Milliken, Auchterlonie & Hoge, 2007; Panagioti, Gooding & Tarrier, 2009). However, research has demonstrated that positive perceptions of social support can reduce the intensity and duration of PTSD symptoms, prevent the development of PTSD, and account for the relationship between PTSD and associated psychosocial difficulties (DeBeer et al., 2014; Kaniasty, 2005). Therefore, perceptions of social support may serve as a valuable predictor for a veteran’s experience of PTSD and associated challenges they encounter during their transition into civilian life. While research has demonstrated the value of strong perceptions of social support 112 in reducing and preventing the negative impact of PTSD among veterans, questions remain regarding how to cultivate social support (Kaniasty, 2005). Nature-based recreation may offer a promising solution because it has demonstrated the capacity to enhance overall psychological wellbeing and reduce symptoms of PTSD among veterans (Vella et al., 2013). More specifically, fly-fishing (J. L. Bennett, Piatt, & Van Puymbroeck, 2017), gardening (Anderson, 2011), and nature-based sports (Lundberg, Bennett & Smith, 2011) have been presented as useful modalities for reducing PTSD symptoms. Nature-based recreation experiences have not only been linked to improvements in psychological wellbeing but improvements in social functioning as well (Duvall & Kaplan, 2014). River running, in particular, has shown to be a promising environment for reducing symptoms of PTSD and increasing social interaction and social support among veterans (C. L. Anderson et al., 2018; Dustin et al., 2011; Scherer et al., 2014). Researchers have postulated that bringing together groups of veterans who share specialized experiences and unique military culture may partially explain the value of nature-based recreation experiences (Bennett, Van Puymbroeck, Piatt & Rydell, 2014). However, identifying social support as a key component of these programs has not been systematically evaluated. Furthermore, modalities that have been evaluated for their therapeutic potential, such as fly-fishing (J. L. Bennett et al., 2017) and gardening (Soga et al., 2017), offer short bursts of nature-based recreation experiences that can occur in groups or independently. Forms of nature-based recreation that extend the amount of time spent in an all-veteran small group context may produce a more sustained impact on perceptions of social support (Dietrich, Joye, & Garcia, 2015) and, subsequently, improve 113 PTSD symptoms. Also, a common symptom of PTSD is avoiding large group or crowded settings (van der Kolk, 2014), so small-group recreation experiences will likely provide a more constructive restorative environment. Therefore, the purpose of this study was to examine the association between nature-based recreation and changes in perceptions of social support over time. 4.2 Research Question 1. Do perceptions of social support for veterans with PTSD change through participation in a river rafting trip? 4.3 Methods 4.3.1 Setting The data for this study were collected before and after two 4-day river trips during the 1st week of September 2018 with four participants on the first trip and eight participants on the second trip (n = 12). The trip took place on the Green River from the Gates of Lodore in Dinosaur National Monument to Split Mountain. On an average year, the water level is relatively low during this season, so the rapids were moderate to small in size (Class I-III). The high desert terrain is composed primarily of steep red rock canyon walls and sagebrush, with frequent animal sightings of bighorn sheep and mule deer. The participants were responsible for bringing their personal gear (e.g., clothes, shoes, waterproof layers, etc.), but the guiding company, OARS, provided personal floatation devices, helmets, tents, sleeping bags, sleeping pads, and food and cooking 114 supplies for the trip. Meals were prepared and served by the OARS guides, but participants were responsible for helping to get everyone’s gear on and off the rafts each morning and evening. Therefore, participants did contribute to the group experience but the setting, required tasks, and necessary gear was accessible enough for people with a range of abilities and diverse socioeconomic backgrounds. At various points on each day of the trip, participants were invited to go on optional short hikes, either when they stopped for lunch or when they arrived at the campsite in the afternoons. These hikes involved viewing historical rock art, such as pictographs and petroglyphs, as well as climbing up to grottos, observing canyon vistas, and standing under small waterfalls. Such excursions were cited as an enjoyable component of the experience, but participation was optional. Not everyone participated in all optional hikes. Freedom of choice in whether to engage in these supplementary activities, as well as choosing which raft to ride on each day provided space for participants to demonstrate control over their social environment. 4.3.2 Participants To recruit participants effectively, efficiently, and from a variety of backgrounds, mixed-purpose sampling, including both maximum variation and purposeful snowball sampling, were used. To maximize participant diversity, informational flyers were provided to VA hospitals throughout the country, as well as local and national organizations that have a reputation of more specifically focusing on the needs of younger veterans. Additionally, organizations that provide specialized services for veterans with a variety of illnesses and disabling conditions were invited to assist in 115 sharing about the trip with people who might qualify for, be interested in, and benefit from the river trip experience. Also, to not limit the search to a particular geographical region, information about the study was circulated on Facebook (VeteransUtah, 2018) using paid advertisements targeted at U.S. military veterans. Once participants expressed interest in the study, purposeful snowballing was used through encouraging potential participants to share information about the study with friends, family members, and/or coworkers who might qualify for and be interested in the study. This allowed the researcher to access veterans who might not have been actively involved in VA services, veteran-specific community-based programs, and/or view advertisements on Facebook. A specific and intentional protocol was used to ensure basic parameters were enforced that identified participant eligibility and maximized participant safety. First, the screening process involved confirming that everyone had military veteran status and participation was restricted to those who had served in the U.S. forces. Additionally, given the most common unique vulnerabilities of the population, participants were screened for current substance dependence, suicidal behavior, and recent hospitalizations (Charles W. Hoge et al., 2004). To ensure that all participants currently met criteria for PTSD diagnosis, the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) was used, which is considered to be the gold standard regarding accuracy and validity for PTSD diagnosis (Weathers et al., 2018). Interviews for the CAPS-5 were conducted by phone by a trained clinician associated with the National Center for Veterans Studies at the University of Utah. Individuals who had a current PTSD diagnosis according to the results of the CAPS-5 116 interview, held military veteran status, and were not contraindicated for participation based on health concerns were invited to participate in the study. All participants were asked to participate through informed consent that aligns with the expressed requirements of the Institutional Review Board at the University of Utah. 4.3.3 Measures The Patient-Reported Outcomes Measurement Information System’s Social Isolation and Emotional Support measures (PROMIS, 2019a), as well as the Social Connectedness Scale (SCS; Lee & Robbins, 1995), were used to evaluate changes in perceptions of social support through participation on the river trip. The assessments were completed 1 month before the trip, 1 day before the trip, 1 day after the completion of the trip, and 1, 3, and 6 months after the trip. The measures that were distributed 1 day before and after the trip were administered as paper surveys, but at all the other intervals, the measures were distributed via email using Qualtrics (2018). After comprehensive literature reviews, focus groups, interviews, and extensive validity testing, the PROMIS measures were developed and officially established by the National Institute of Health in 2004 (PROMIS, 2019b). Further investigation, including exploratory and confirmatory factor analysis, repeatedly confirmed the reliability and validity of these measures, as well as contributed to their ongoing refinement and development (Cella et al., 2010). The current iteration of the PROMIS measures exists in various forms, covering multiple dimensions of physical, mental, and social health (PROMIS, 2019b). The PROMIS Social Isolation (PROMIS-SI) measure is specifically designed to 117 evaluate adults’ perceptions of social support. More specifically, “the PROMIS-SI items assess an individual’s perception of being excluded, detached, disconnected from, unknown, or avoided by others and include the perceived quality of interpersonal relationships, social network, companionship, feeling cared for, valued, of belonging, and trust” (Karayannis, Baumann, Sturgeon, Melloh, & Mackey, 2018, p. 3). The PROMISSI is a 4-item measure with questions such as, “I feel isolated from others,” and “I feel that people barely know me,” using a 5-point Likert Scale ranging from “never” to “always” (PROMIS 2008-2016). In measure testing, the PROMIS-SI consistently demonstrates strong reliability ( > 0.95) (PROMIS, 2015). This measure has been applied to diverse settings and populations, ranging from the influence of social media use on perceptions of social isolation among young adults (Primack et al., 2017) to the impact of social isolation on pain interference (Karayannis et al., 2018). However, the PROMIS-SI measure has only been used once to evaluate the social outcomes of nature-based recreation (Heilmayr, 2017). Similarly, the PROMIS-ES measure has been used to identify social outcomes for different populations in various settings, but with a clear emphasis on clinical environments. For example, it has been used to measure the relationship between cancer patients’ expectations and their associated perceptions of emotional support (Adams et al., 2017). It has also recently been used to evaluate the potential value of video conferencing in reducing emotional loneliness among people in long-term care (Siniscarco, Love-Williams, & Burnette-Wolle, 2017). The PROMIS-ES measure asks four questions on a 5-point Likert Scale that indicate social support, such as, “I have someone to talk with when I have a bad day,” and “I have someone who makes me feel 118 appreciated” (PROMIS 2008-2016). In measure testing, the PROMIS-ES consistently demonstrates strong reliability ( > 0.98) (PROMIS, 2017). However, it has yet to be applied to the evaluation of social support in nature-based recreation. Conversely, the SCS has been used to identify the social outcomes of various forms of nature-based recreation. For example, Duvall and Kaplan (2014) used the SCS to evaluate the benefits of extended group-based nature recreation experiences for veterans. Another study used the SCS in an environmental education context to measure the social outcomes of student participants (Lankenau, 2012). Still others have used the SCS to measure changes in social connection through outdoor adventure programs for young people with mental illness (Schell, Cotton, & Luxmoore, 2012), campers’ sense of connection with each other and adults through participation in outdoor education (Frame, 2017), and the social benefits of fishing during adolescence (Leonard, 2015). Therefore, the application of the SCS to nature-based recreation research has thus far been reasonably broad and diverse. The more widespread use of the SCS in evaluating the social outcomes of naturebased interventions may simply be a function of the fact that it has existed for a longer period than the PROMIS measures. The SCS was first created in 1995 and demonstrated significant test-retest reliability (Lee et al., 1995), and was later revised to reduce the potential biasing effect of phrasing the questions in a negative direction and more comprehensively, “capture the full experience of connectedness” (Lee, Draper, & Lee, 2001, p. 311). In its current version, the SCS is an 8-item 6-point Likert Scale evaluating social support through questions such as, “I have no sense of togetherness with my peers,” and “Even around people I know, I don’t feel that I really belong” (Lee et al., 119 1995). Reliability testing has revealed an alpha of .91 for the SCS (Lee et al., 1995). 4.3.4 Data Analysis This study utilized a within-group pre/posttest design. As none of the measures had subscales, mean composite scores at each interval were calculated for each scale. Scores from repeated-measures one-way analysis of variances (ANOVA) with a Least Significant Difference (LSD) post-hoc analysis were performed in SPSS (Version 25) to compare changes in perceptions of social support at each time point. An LSD post-hoc test was selected because the risk of Type I error in this data set was low and this test has greater statistical power than other post hoc tests, which was beneficial given the small sample size (Field, 2015). Sphericity was confirmed using Stata (version 15). Alpha was established at p < 0.05 for all analyses, and a power analysis was conducted using the G*power 3.1 program. Data were missing from all of the measures for one participant at 1, 3, and 6 months posttrip. Also, one participant did not complete the PROMIS-ES the day before the trip, one participant skipped an item on the PROMIS-SI the day before and the day after the trip, and one participant skipped an item on the SCS the day before the trip. Cases with missing data were dropped. A one-way Analysis of Covariance (ANCOVA) was used to determine any differences between groups of participants based on age, gender, and rural versus urban location. No significant differences in perceptions of social support over time were found between participants based on these demographic variables, so all subjects were collapsed into one group. 120 4.4 Results The research participants included 12 veterans with PTSD, four women, and eight men, from throughout the United States. Four of the participants lived in rural locations, and eight lived in urban locations. Eight identified as White and not Spanish/Hispanic/Latino; three identified as White and Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, or other Spanish/Hispanic/Latino; one identified as Black or African American; and one identified as American Indian or Alaska Native. Five participants were 23-33 years old, five were 34-45 years old, and two were 46-54 years old. All of the participants identified as heterosexual or straight; three were dating, engaged, or in a committed relationship; eight were married; one participant was separated or divorced; and all but one of the participants had children. As shown in Table 4.1, mean scores for PROMIS-ES steadily increased from pretrip (M = 3.56, SD = 0.71) to posttrip, which is an indication of improvement in perceptions of social support. Improvements were unique for this measure in that they continued through the 3-month follow-up (M = 4.16, SD = 0.86) before dropping slightly, but not returning to pretrip levels, at the 6-month follow-up (M = 3.80, SD = 1.19). Mean scores for PROMIS-SI steadily increased from pretrip (M = 2.33, SD = 0.81) until the day after the trip (M = 2.80, SD = 0.84), which is an indication of improvement in perceptions of social support. A decrease in mean scores was observed at the 1-month follow-up (M = 2.52, SD = 1.07), with a steady decline continuing through the 6-month follow-up, which dropped below pretrip levels (M = 2.25, SD = 0.76). Mean scores for the SCS steadily increased from pretrip (M = 2.59, SD = 1.02) until the day after the trip (M = 3.57, SD = 0.97), which is an indication of improvement in perceptions of social support. A decrease 121 Table 4.1 Descriptive statistics Emotional Support Interval Mean Standard Social Isolation Mean Deviation Standard Social Connectedness Mean Deviation Standard Deviation Pretrip 3.56 0.71 2.33 0.81 2.59 1.02 Day before 3.68 0.95 2.48 0.90 3.20 1.14 Day after 3.88 0.79 2.80 0.84 3.57 0.97 1-month after 4.00 0.98 2.52 1.07 3.19 1.45 3-months after 4.16 0.86 2.48 0.79 3.31 1.42 6-months after 3.80 1.19 2.25 0.76 3.17 1.26 in mean scores was observed at the 1-month follow-up (M = 3.19, SD = 1.45), with a slight increase 3-months after the trip (M = 3.31, SD = 1.42), and a decrease again at the 6-month follow-up that did not return to pretrip levels (M = 3.17, SD = 1.26). Responses demonstrated greater variation for social connectedness than for social isolation and emotional support. A one-way within-participants ANOVA was calculated with emotional support as the dependent variable and time as the independent variable. The assumptions of homogeneity of variance, approximately normal distribution, and sphericity were met. As seen in Table 4.2, there was not a significant effect of time on emotional support, F(5, error) = 0.622, p = 0.684 (r = .048). An LSD post-hoc test revealed that the emotional support scores were not significantly different at each time interval, but emotional support levels from pretrip to the 3-month follow-up started to approach significance (p = .126). A one-way within-participants ANOVA was calculated with social isolation as 122 Table 4.2 Analysis of variance for emotional support Between Groups Within Groups Total Sum of Squares 2.64 df 5 Mean Square .53 52.60 62 .85 55.24 67 F P .622 .684 the dependent variable and time as the independent variable. The assumptions of homogeneity of variance, approximately normal distribution, and sphericity were met. As seen on Table 4.3, there was not a significant effect of time on social isolation, F(5, error) = 0.521, p = 0.759, (r = 0.041). An LSD post-hoc test revealed that the social isolation scores were not significantly different at each time interval. A one-way within-participants ANOVA was calculated with social connectedness as the dependent variable and time as the independent variable. The assumptions of homogeneity of variance, approximately normal distribution, and sphericity were met. As seen on Table 4.4, there was not a significant effect of time on social connectedness, F(5, error) = 0.765, p = 0.579 (r = .058). An LSD post-hoc test revealed that the social connectedness scores were not significantly different and were not approaching Table 4.3 Analysis of variance for social isolation Between Groups Within Groups Total Sum of Squares 1.95 df 5 Mean Square 0.39 45.69 61 0.75 47.64 66 F P 0.521 0.759 123 Table 4.4 Analysis of variance for social connectedness Between Groups Within Groups Total Sum of Squares 6.16 df 5 Mean Square 1.23 99.81 62 1.61 105.97 67 F P .765 .579 significance at each time interval. Given the small sample size, a type II error may have occurred, indicating nonsignificance when significance actually exists because a small data set runs the risk of not being able to have the statistical power to detect significant changes. A power analysis was conducted using a 0.3 effect size to assess this possibility. The findings indicate that a sample size of 24 people would be necessary to have sufficient power to minimize the risk of a type II error. Therefore, the nonsignificance of these findings could reasonably be a product of inadequate sample size, rather than not observing significant changes in perceptions of social support over time. Consequently, this should be considered a pilot study, and these findings should be interpreted as exploratory in nature. 4.5 Discussion The findings of this study provide preliminary data regarding the potential changes in perceptions of social support following participation in a river trip for veterans with PTSD. Perceptions of social connectedness, social isolation, and emotional support improved from pre- to posttest, but were not sustained 6-months posttrip. For social connectedness and social isolation, improvements continued through 1-month after the 124 trip, and for emotional support, improvements were sustained 3-months after the trip. However, these changes were not statistically significant, potentially due to a small sample size and, therefore, lack of statistical power to detect significant change. Given the overall mean changes, preliminary results indicate significant changes over time may exist, so it would be beneficial for further research to be conducted that evaluates these outcomes with a larger sample of veterans with PTSD. Additionally, continued advancements in social support from 1-day to 1-month posttrip might be a product of the disruptive and unfamiliar nature of the trip itself, producing distorted posttrip findings immediately after the trip, but more reliable findings once the participants have returned to their everyday life. This concept is consistent with the findings of outdoor education research that has identified ways in which immediate posttrip results from such adventure-based trips can be misleading due to the intensity and euphoria of such experiences (Hattie, Marsh, Neill, & Richards, 1997). Also, based on the qualitative findings of Tysor (2019), it is expected that greater improvements in social support would be observed once the individual has returned home and settled back into their familiar social environment occupied by their important, lasting, everyday relationships. Without an adequate sample size, however, these initial findings are only preliminary indications of the potential value of these trips for improving perceptions of social support for veterans with PTSD. 4.6 Limitations Every research study has limitations and, in this case, the lack of a control group makes it difficult to attribute any changes in perceptions of social support to the river trip 125 itself (Pithon, 2013). Only two people met the criteria for participation and did not attend the trip, providing an inadequate number of people eligible to serve as a control group. Also, the small sample size made it difficult to produce statistically powerful results. The rigorous nature of the study may have contributed to difficulties associated with participant recruitment. More specifically, the use of the CAPS-5, while highly effective in ensuring the accuracy of PTSD diagnosis, requires all participants discuss aversive details related to their traumatic experiences before being invited to participate in the study. Given the difficulty many people with PTSD face in discussing details related to their traumatic experiences (Smyth, Hockemeyer, Heron, Wonderlich, & Pennebaker, 2008), this may have created a substantial barrier to participation that hindered recruitment and contributed to the small sample size. These limitations have the potential to be addressed in the near term. Additional funding to continue the study in the fall of 2019 will provide the opportunity to gather more data. Hopefully, this will allow the researchers to recruit enough participants to ensure more statistically powerful results and potentially provide enough people to form a control group. 4.7 Conclusion The purpose of this study was to examine the association between nature-based recreation and changes in perceptions of social support over time. Perceptions of social support for veterans with PTSD improved on all three measures from pretrip to posttrip, most notably from the day before the trip to the 1-month follow-up. While the data analysis did not indicate that these improvements were statistically significant, a Type II 126 error may have occurred due to the small sample size. Future research has the potential to provide additional statistical power for analysis, as well as additional information regarding the attribution of changes to the river trip through the use of a control group. Preliminary findings indicate that improvements in perceptions of social support over time may exist but are not sustained at the 6-month follow up. Additional research is necessary to confirm the statistical significance of these improvements. CHAPTER 5 CONCLUSION The purpose of the three preceding articles was to explore the social benefits of nature-based recreation (NBR) for veterans with PTSD. Results from the scoping review of existing research on the social outcomes of NBR, the qualitative analysis of the social environment that emerged during a river rafting trip for veterans with PTSD, and the quantitative analysis of changes in perceptions of social support over time for veterans with PTSD collectively enhance the depth and richness of understanding of the social benefits of NBR for veterans with PTSD. Throughout this chapter, the findings from these three studies will be interpreted, interconnected, and generalized through the lens of the Bioecological Model (BEM) of human development. Additional reflections regarding this research will also be discussed. 5.1 Results Through the Lens of the BEM The BEM posits that increasingly complex changes in human development occur through the reciprocal influence of proximal processes, person characteristics, contextual factors, and time (Bronfenbrenner & Morris, 2006). The primary developmental outcomes of interest within this research are social in nature, including perceptions of social support, social skill development, interpersonal experiences within a veteran- 128 specific nature-based context, and ongoing experiences of and engagement with everyday social settings. Also, all three articles were fundamentally united through their focus on a particular set of person characteristics (e.g., veterans with PTSD) and contextual factors (e.g., NBR) that were expected to contribute to social outcomes. The two primary personal characteristics of interest were veteran status and PTSD diagnosis, and the primary context of interest was recreation in a nature-based environment. However, each article produced unique information that can be differentially interpreted through the conceptual framework provided by the BEM, with a focus on the processes, person characteristics, contextual factors, and time-related factors that interactively contributed to social development. For example, the scoping review revealed that the majority of the research on the social outcomes of NBR has focused primarily on groups of people with a limited range of shared person characteristics, most notably veterans, people with disabilities, and university students. The BEM recognizes that the personal characteristics of individuals within a group context can influence the context itself, and the context can influence individual characteristics. Therefore, conducting research that focuses on trips that are composed of people who share important components of their identity, such as veteran status, disability status, and university student status, could potentially be influencing the social environment that emerges, as well as the social outcomes that are produced at the individual level. This limits the possibility of confidently using the findings present in the scoping review to conclude that it is the outdoor context of NBR that is responsible for producing the social outcomes observed. This certainly seemed to be the case given the veracity with which the veterans 129 expressed an appreciation for having multiple shared identities with people on the river trip, including veteran status and shared mental health challenges. They repeatedly expressed that the social environment and their behavior would have been completely different if the river trip had been composed of primarily civilians, or even a balance of both veterans and civilians. From their perspective, having a veteran-specific trip was essential to the positive social environment that was produced during the trip, as well as the lasting impact the trip had on their everyday social life. However, additional research must be conducted to better understand the extent to which the social group or the outdoor environment is the primary contributor to changes in social support. Certain personal characteristics were identified by some of the trip participants as influential regarding the way they interacted with the social environment on the trip. Gender, for example, was verbally identified as a noninfluential factor during interviews, but data derived from observation and documentation seemed to indicate that it was a socially influential demand characteristic. One of the group members found that being the oldest member of the group was, occasionally, a personal characteristic that caused them to be excluded from the social context. Also, a few of the veterans mentioned how resources that were cultivated or depleted during their service experience impacted the way they socialize, either by providing them with the skills necessary to interact with groups of people or increasing social anxiety. Biological processes specific to veterans with PTSD also were likely influencing the social environment that emerged during the river trip, as well as the changes in perceptions of social support that occurred and the changes in everyday relationships that many of the participants experienced. Traumatic brain injury (TBI) has become quite 130 common among those returning from military service in recent years, particularly among those who served in combat (Snell & Halter, 2010). A TBI produces cognitive deficits that frequently inhibit social functioning, create barriers to receiving quality social support, and influence the social dynamics that develop in social settings (Bogdanova & Verfaellie, 2015). Therefore, those conducting future research on the social benefits of NBR for veterans may benefit from conceptualizing TBI as a potential confounding variable. Within the context of the quantitative article conducted in this dissertation, only two of the participants had a TBI, and they were both on a trip that was not qualitatively evaluated. Interestingly, the two people with TBIs were the only individuals who skipped questions and did not complete all of the follow-up surveys. Future researchers, therefore, might further improve the quality and completeness of their data by providing additional support during the data collection process to account for potential cognitive deficits experienced by participants who have a TBI. In addition, the unique lack of conflict during the river trip that was qualitatively analyzed was likely influenced by the fact that none of the participants on the trip had a history of TBI. This may have reduced the risk of any of the veterans demonstrating inappropriate or challenging social behavior. Overall, a veteran’s history of TBI should be considered a personal characteristic that not only influences social contexts, but also the data collection portion of research processes. Another biological characteristic of the people who participated in NBR that may have influenced and been influenced by social processes is the neurobiology of PTSD. Traumatic events can leave a lasting impression on the functioning of an individual’s 131 limbic system, particularly the amygdala, which serves the valuable purpose of helping people detect and respond quickly to potentially dangerous situations but, when overactivated, makes it difficult to relax fully and effectively socialize in peaceful, everyday situations (van der Kolk, 2014). As a consequence, veterans with PTSD are disproportionately inclined to perceive stimuli as harmful or threatening when no real danger exists (Hoge, 2010). This contributes to social isolation and withdrawal from settings that the individual perceives as unsafe or chaotic (APA, 2013). The neurological impact of PTSD also frequently produces an aversion to the noisy chaos of crowds (C. W. Hoge, 2010). Consequently, the loud noises and crowdedness of urban environments can heighten PTSD symptoms, which was reflected in the data from the qualitative analysis of the social environment on the river trip. Also, an individual’s PTSD symptoms can cause them to disproportionately favor nonurban environments and demonstrate a selective preference for nature-based settings. Therefore, NBR occurs in a context that is both well-suited to the preferences of an individual with PTSD and more conducive to reducing or minimizing PTSD symptoms. Given the fact that PTSD symptoms can dampen the prefrontal cortex and, subsequently, inhibit social functioning, a NBR context may be particularly ideal for calming the amygdala, activating the prefrontal cortex (Shin et al., 2006), and, subsequently, providing the opportunity for veterans to successfully socialize and receive much-needed social support (van der Kolk, 2014). The biological characteristics associated with PTSD may also enhance the quality of the social context during NBR experiences. By providing trips that are specifically tailored to people who not only have shared military service experiences but also have 132 similar mental health challenges, a base level of shared understanding may provide a particularly safe and stable social context for veterans. This likely contrasts with the cultural macroenvironment of civilian-dominated settings, or other cultural contexts where PTSD is heavily stigmatized. Having shared mental health experiences also provides a unique opportunity for resource sharing in regard to coping with PTSD symptoms. This shared understanding and resource sharing may have contributed to some of the findings in the scoping review, the improvements in perceptions of social support following the river trip, and the level of social comfort and appreciation for resource sharing experienced by veterans during the river trip. Another shared characteristic of the veteran community that may contribute to the social dynamic that emerges in nature-based environments is a propensity toward helpfulness (Coates & Matthews, 2017). Veterans are disproportionately likely to volunteer and serve in their community when compared to their civilian counterparts (Coates & Matthews, 2017). The river-trip context provides a unique opportunity for this characteristic to flourish as participants can assist each other while unloading gear from the boats, pushing themselves physically (e.g., while hiking, kayaking, etc.), and when setting up and breaking down camp each day. Veterans’ propensity to assist others combined with the opportunity to capitalize on that tendency has the potential to not only facilitate posttraumatic growth and recovery (Wilson, 2005) but also enhance the quality of the relationships that develop during the trip (Miller, 2012). The BEM also posits that experiences in one context can influence changes or effects in another context, particularly at the microsystem-level (Newman & Newman, 2016), which is a phenomenon that was observed in these studies. For example, in the 133 qualitative analysis, the microsystem that existed during the river-trip context impacted participants’ everyday microsystems. The impacted microsystems included a range of contexts, from the quality of friendships and family relationships to experiences in crowded groups and engagement in public spaces. The quantitative analysis demonstrated comparable developmental changes in that perceptions of social support increased once participants returned to their home life. Socializing in a small group microsystem over time may also play a role in the social outcomes of NBR. For example, the scoping review found that existing research has been conducted using forms of NBR that involve a wide variety of time frames, from a few hours to multiple weeks. Researchers should consider the potential value of conducting a meta-analysis of the social outcomes of NBR to determine if the amount of time involved in the NBR experience has a statistically significant impact on the social outcomes that are produced. Others have proposed the importance of considering longer trips, lasting more than a week, specifically when looking at social outcomes (Dietrich et al., 2015), but such data collection often proves unfeasible and impractical for the average researcher. Also, data collection for the qualitative analysis was specifically designed in a way that accounted for the relevance of time in contributing to developmental processes. For example, the interview was not conducted until the 3rd day of the trip based on the expectation that it would take time for group dynamics to form. Furthermore, the veterans’ level of social comfort was expected to improve over time as they built relationships with fellow group members, which led to specifically asking them in the interview, “Has your level of social comfort changed over the last few days? If so, how?” 134 Interestingly, veterans unanimously responded by discussing the progressive reduction in anxiety they experienced with each day that passed on the river. Also, follow-up interviews showed the time that passed after the river trip influenced their social development within their everyday life. Time had an impact on the way they were influenced by the river trip context. The quantitative analysis of social support inherently accounting for the impact of time by measuring perceptions of social support at six different time points throughout seven months. Researchers have also found that time is an important factor in that the social support received immediately following a traumatic event can dramatically influence an individual’s health and wellbeing, including a person’s risk of developing PTSD (Dietrich et al., 2015). A meta-analysis regarding the risk factors for PTSD in traumaexposed adults found that the absence of a socially supportive microsystem is the single greatest predictive factor for whether a person will develop PTSD following a traumatic event (Brewin, Andrews, & Valentine, 2000). Given the consideration of these study findings with the context of the BEM, potential opportunities for theory-building could be considered by future researchers. Most notably, the quantitative analysis of changes in perceptions of social support found that demographic variables did not significantly impact the findings. The BEM, however, posits that the principal main effects are likely to be interactions (Bronfenbrenner & Morris, 2006). Therefore, ANCOVA results testing the statistical relevance of demographic variables were to be expected to be significant. However, within the context of this research, personal characteristics such as age and gender, as well as the contextual factor of urban versus rural location, were not found to be statistically influential 135 regarding the social outcomes that were produced. While these factors may have been perceived as influential during participants’ experiences during the river trip, their influence was not statistically significant. BEM theorists may consider the possibility that whether or not interactions are the main effects may be a function of the contextual circumstances involved, personal characteristics of participants, and outcomes that were analyzed. For veterans reintegrating into civilian life who do not have quality social support systems in place, which is more likely to be the case among veterans when compared to the civilian population (Tanielian & Jaycox, 2008), receiving evidence-based services that enhance social support in a timely manner could have dramatic implications for their long-term health. Therefore, when considering effective nontraditional responses to the threat of PTSD among the veteran population, individual characteristics, context circumstances, timely responsiveness, and the continual interactions between individuals and their environment all seem to influence the social outcomes that are produced. Veteran-specific NBR experiences that enhance social support immediately following deployment demonstrate promising potential to bolster social support and can be used as a preventative measure against PTSD, rather than simply using it as a recovery tool after PTSD has already developed. 5.2 Final Reflections Overall, the research encapsulated in these three articles presents new information with a variety of potential implications for future research, additional questions to consider, and challenging situations unique to this type of research. Future researchers 136 could benefit from learning from the difficulties encountered throughout this research process. Generally, this type of research seems to present particularly unique difficulties that might not have simple or straightforward solutions. Also, these articles, in many ways, only begin to scratch the surface on a range of complex topics related to the social benefits of nature-based recreation for veterans with PTSD. Only through ongoing, collaborative efforts of dedicated researchers can more definitive conclusions begin to be drawn on these topics, particularly regarding the mechanisms at play within the NBR environment that are responsible for influencing social outcomes. One of the greatest challenges encountered during this research process was the recruitment of an adequately sized group of participants for the river rafting trip. The evaluation of social outcomes during the river trip was situated within a larger study evaluating the mental health benefits of NBR for veterans, military service members, and their families. Across all portions of the study, the researchers faced tremendous difficulty in trying to get interested participants to fully complete each stage of the recruitment process and follow-through on their intent to attend and contribute. For the river rafting trips, one-quarter of the people who expressed interest went on to submit their IRB consent form, and from within that group, less than half completed the qualifying phone interview. Of those who completed the interview and qualified, nearly a quarter decided not to attend, usually canceling within 2 weeks leading up to the trip. Those who chose not to attend at the last minute cited family or work-related time conflicts, important medical appointments that they either could not or were unwilling to reschedule, and concerns about physical limitations that might make the trip uncomfortable. When offered potential solutions, such as attending a different trip during 137 alternate dates or borrowing more comfortable camping supplies, their reasoning for not attending often changed. Their concerns might have been genuine, but during the river trip itself, multiple participants discussed how they were nervous about attending a new experience in an unfamiliar part of the country with a group of strangers and nearly decided to cancel at the last minute based on these fears. Regardless of the actual reasons for high rates of attrition, barriers to recruitment certainly exist that limit the generalizability of these research findings and limit the statistical power of the quantitative analyses. Recruitment difficulties also make it challenging to create a quality control group because everyone in the control group at the very least needs to submit a consent form and complete the qualifying phone interview. This limits the capacity of the researchers to attribute the findings to the river trip itself. Based on how rarely studies included in the scoping review had control groups, this may be a common problem faced by those conducting NBR research. This makes it difficult to definitively conclude that naturebased environments themselves are the factors that lead to the social outcomes NBR produces, rather than the group environment that exists, which is a consistent factor across all studies included in the scoping review. Without having comparable groups participate in similar activities in a non-nature-based setting, it makes it difficult to identify precisely what occurs during these trips and which elements of the trips lead to the outcomes that are produced. It can be said, however, that participants cited the unique characteristics of the outdoor natural environment that facilitated more processes that engender perceived social support. Choices made by the researchers during recruitment for the river trips may have 138 contributed to the challenges encountered during this process. Most notably, the use of the CAPS-5, while considered the gold standard in accurately determining whether or not an individual meets criteria for PTSD (Weathers et al., 2018), created a barrier to participation for many participants. The interview occurs by phone with a clinician and takes anywhere from 45 minutes to 2 hours. It starts by discussing a traumatic event that has most negatively influenced the person’s every life. Next, interviewees answer questions regarding the various ways this event has disrupted their everyday experiences, from avoiding people and places to harboring negative beliefs about themselves or others. Potential participants often hesitated to schedule their CAPS-5 interview once they received information about what it would entail. Others started the interview process and stopped midway through because it was too upsetting to discuss aversive details related to their traumatic experiences and the impact these experiences have had on their lives. Others completed the interview process but, once they were on the river trip, discussed how upsetting that part of the research process was for them. Those who completed the CAPS-5 interview but ultimately did not meet diagnostic criteria for PTSD often became quite upset when they received the news that they did not qualify for the trip after enduring such an emotionally challenging interview process. A possible solution to this issue would be to use different, less psychologically challenging methods for identifying whether or not potential participants meet diagnostic criteria for PTSD. For example, the PCL-5 is commonly used in research and clinical practice to screen individuals for PTSD and track changes in PTSD symptoms over time (Weathers et al., 2013). However, as a 20-item self-report measure that takes 5-10 minutes to complete, it is far less cumbersome than the CAPS-5 interview process and 139 can be filled out at a participant’s leisure in the comfort of their own home (Weathers et al., 2013). For future studies, researchers should consider the potential value of slightly compromising methodological rigor by not using the gold standard for PTSD diagnosis to reduce barriers to participation and minimize participant burden. As research studies so often do, these studies produce more questions than answers and have certain limitations. For example, within the scoping review, were the social outcomes produced by the activities that took place in a group context, was it the nature-based environment that led to the social outcomes, or was it a combination of activities, group settings, and the nature-based environment? As seen in the scoping review, nearly all NBR research that evaluates social outcomes, including the riverrafting trips analyzed here, look at group-based experiences that are facilitated. In the absence of control groups that look at comparable environments, but occur on a solobasis and in a nonfacilitated setting, direct associations between the nature-based environment and the social outcomes cannot be definitively drawn. An argument could be made that it is the group-based experiences in a facilitated-setting, not the NBR setting itself, that produce the social outcomes. Perhaps similar outcomes could be generated through a facilitated, group-based experience at an urban spa or other built environment. If studies looked at identical social outcomes using the same measures among comparable samples and utilized similar recreational activities, but modified the setting to evaluate social outcomes in highly diverse nature-based environments, would different social outcomes be produced? Is there an optimal nature-based environment for producing social outcomes? Conducting such research would require phenomenal financial and time-related resources. 140 Similarly, are there ideal activities that take place in nature-based settings that would optimize social outcomes? The river rafting context is a particularly unique form of NBR in that it is both water- and land-based is intensely removed from urban environments with essentially no access to technology or digital services, and provides limited physical space for participants, which forces them to interact more than they might choose to otherwise. When backpacking, for example, people often pass through local towns, often enter into and out of cellular service, and can simply walk faster or slower if they would like to spend more time alone. On these river trips, however, campsites and rafts were only so big, limiting the ability to escape fellow participants, and cellular access stopped at the start of the trip and did not resume until the take-out. This provided a unique form of removal from everyday life and immersion into the group context that would not necessarily be required of other forms of NBR, such as gardening, participating in single-day challenge courses, and urban-proximate hiking. Melton (2017) claims that certain types of activities are more conducive to producing social outcomes. Within the context of family leisure, Melton poses the Family Activity Model (FAM), which combines the core and balance model of family leisure with Orthner’s joint and parallel activities constructs. Melton (2017) claims that joint activities, which involve a high degree of participant interaction, are more conducive to relational satisfaction than parallel activities, which occur in proximate space but do not require participant interaction. He also notes that participants should have basic familiarity with the activities they participate in so that they can allocate quality attention to relationships with fellow participants without becoming overwhelmed by the activities. However, activities should also be novel enough that participants do not become bored 141 (Melton, 2017). Therefore, NBR activities that balance novelty with familiarity and that require participant interaction would be optimal for producing social outcomes (Melton, 2017). Melton’s FAM suggests that, within the river trip context, participants who feel comfortable in outdoor settings or have been camping before would likely experience greater social benefits than people who are not familiar with NBR. Conversely, participants with extensive river-rafting experience might experience fewer social benefits because river trips do not provide sufficient novelty. The FAM also indicates that the river trips from these studies might be particularly conducive to producing social outcomes when compared to other NBR activities in that, through sharing a boat ride, transporting gear to and from the boats, hiking together, and playing games at camp, they involve group member interaction (Melton, 2017). The findings indicate that social changes were particularly evident when participants returned to their everyday social life, and veterans generally did not stay in touch with fellow participants who lived far away. Therefore, would trips that are specifically designed for groups of veterans who already know each other, such as reunions for veterans that served together, produce even more robust social outcomes? Furthermore, could river trips be used for veterans immediately upon their return from service specifically for veterans who live in similar geographical regions to proactively cultivate social support? Could this strategy be used to preventatively address the many social issues veterans often encounter during reintegration? Additionally, researching less expensive and more readily accessible forms of NBR could prove useful when evaluating types of recreation that could be used to 142 improve the health, wellbeing, and social functioning of veterans with PTSD. Veterans disproportionately come from disadvantaged backgrounds and often have few options outside of returning to those social environments upon discharge (Tanielian & Jaycox, 2008). Also, people with disabilities, including people with PTSD, tend to be overrepresented among those who are poor, undereducated, and unemployed (U.S. Department of Labor, 2017). Since it seems unlikely that river trips could be universally provided free of charge and as-needed to veterans with PTSD, researching more financially accessible forms of NBR that could be used as needed by veterans might prove beneficial, if researchers’ intent is to truly identify practically constructive environments that promote the health and wellbeing of veterans with PTSD. Nevertheless, the research presented in these articles provides new and interesting information regarding the social benefits of NBR for veterans with PTSD. Through a scoping review, a qualitative analysis of a rafting trip, and a quantitative evaluation of changes in social support over time, NBR was found to produce potentially valuable social outcomes for this population. Through further investigation and continuing to rigorously and comprehensively evaluate the various factors involved in these experiences, researchers will begin to parse out the different components of these experiences that lead to the social outcomes that are produced for veterans with PTSD, thereby expanding our understanding of the new and diverse ways for veterans to experience improvements in health, growth, connection, and recovery. APPENDIX MET ANCOVA ASSUMPTIONS AND CONTROLLED FOR DEMOGRAPHIC VARIABLES Emotional Support Emotional support ranged from 1 to 5 (M = 3.84, SD = 0.91). Emotional support was normally distributed, as evident through histogram analysis. For emotional support, the assumption of homogeneity of variance was met (p = 0.78). When correction for a potential violation of the assumption of sphericity through running the data in Stata, the results for emotional support remained nonsignificant (p = 0.55). Therefore, even if the assumption of sphericity was violated, the correct results would produce comparable findings. Social Isolation Social isolation ranged from 1 to 5 (M = 2.47, SD = 0.85). Social isolation was normally distributed, as evident through histogram analysis. For social isolation, the assumption of homogeneity of variance was met (p = 0.94). When correction for a potential violation of the assumption of sphericity through running the data in Stata, the results for social isolation remained nonsignificant (p = 0.25). Therefore, even if the assumption of sphericity was violated, the correct results would produce comparable findings. Social Connectedness Social connectedness ranged from 1 to 6 (M = 3.17, SD = 1.26). Social isolation was normally distributed, as evident through histogram analysis. For social connectedness, the assumption of homogeneity of variance was met (p = 0.54). 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