Improvement in Veterans' Openness to Seeking Professional Psychological Help After Participating in Therapeutic Adventure Trips

Abstract

Despite high rates of mental illness among veterans, many do not receive sufficient mental health treatment. Thus, mental health interventions that do not look like treatment, but look more like outdoor recreation, may be helpful in addressing veterans' resistance to mental treatment and help-seeking. The present study sought to answer the question: Does participation in a therapeutic adventure program correlate with veterans' help-seeking for mental health concerns? If such correlations exist, which demographic or military service-related factors might help explain those patterns of change? Participants in the present study attended a peer-led therapeutic adventure trip that lasted at least 3 days and 2 nights. The 67 participants completed study measurements pre-trip, immediately post-trip, 1-month post-trip, 6 months post-trip, and 12 months post-trip. Using latent growth curve modeling, results showed that, on average, veterans who attended these trips increased their openness to seeking professional psychological help significantly from pre-trip to 1-year post-trip. Notably, the rate of increase for males was slower than for females. Results also showed significant variability in the starting point and the trajectory of seeking professional psychological help. The findings suggest that veterans show variability in their openness to seeking professional psychological help after therapeutic adventure participation and may vary significantly in how open they become over time. The present study provides evidence that veterans' participation in therapeutic adventure trips correlates with increased openness to seeking professional help, suggesting the intervention's possible role in improving veterans' help-seeking behaviors.

Introduction

Military veterans experience mental health challenges at alarmingly high rates. In a study of nearly 4.5 million veterans, more than a quarter reported at least one diagnosable mental health disorder, including post-traumatic stress disorder (PTSD: 9.3%), depression (13.5%), substance use disorders (8.3%), anxiety disorders (4.8%), and other “serious mental illnesses” (3.7%) (Trivedi et al., 2015, p. 2565). Among all veterans, PTSD is the most frequently diagnosed mental health disorder (Ramsey et al., 2017).

Recent research estimates that 23% of Operation Enduring Freedom and Operation Iraqi Freedom veterans who use Veterans Affairs (VA) health care services have PTSD (Fulton et al., 2015). In 2019, the adjusted suicide rate for veterans was 52.3% greater compared with civilian adults with an average of 17.2 veteran suicides per day (U.S. Department of Veterans Affairs, 2021). Despite this elevated suicide risk, one study found that only a third of veterans experiencing suicidal ideation are engaged in mental health treatment (Nichter et al., 2021). Veterans who have diagnoses of depression, substance use disorder, and other serious mental illnesses are at a particularly high risk of hospitalization and death (Trivedi et al., 2015).

Veterans' barriers to entering mental health treatment

Despite high rates of mental illness, many veterans do not receive sufficient treatment for these illnesses (Jakupcak et al., 2013; Johnson & Possemato, 2021). Although the VA health care system utilizes numerous evidence-based, manualized, short-term approaches to mental health treatment, VA providers have encountered barriers in delivering these efficacious treatments to veterans, including high rates of no-shows to treatment and veteran beliefs that mental illness will be life-long and unchangeable (Hamblen et al., 2015; Karlin et al., 2010).

Low utilization of treatment for mental health can partly be attributed to interactions with the VA, as more than two-thirds of veterans report that negative experiences with VA health care create barriers to accessing and continuing care (Hundt et al., 2018). These issues include “red tape,” negative experiences with providers, beliefs that the environment is unsafe, and difficulty navigating the system (Hundt et al., 2018). Notably, one study found that concerns over how the stigma of mental health issues may negatively impact career prospects were the strongest predictor of veterans' willingness to seek treatment (Brown & Bruce, 2016).

Notably, some veterans express fear about opening up to civilian providers outside of the VA who may not understand military culture (Wray et al., 2016). Military culture fosters hyper-masculinity, a culture of self-sacrifice, and a warrior mentality without room for weakness (Shields et al., 2017). In one study, veterans reported beliefs that depression is weak, unmanly, and cowardly; they also noted concerns about being labeled as “crazy” or being pitied (Rodrigues et al., 2014). Military values prioritize the mission over personal needs (Wray et al., 2016), which can inhibit the development of help-seeking attitudes among military populations. In such a context, mental health issues may be viewed as failure (Shields et al., 2017).

Notably, research points to gender as a potential barrier, with especially low utilization rates of mental health treatment among young male veterans (Jakupcak et al., 2013). Male veterans appear to hold more negative beliefs about both mental health issues and mental health treatment than female veterans (Fox, Meyer, & Vogt, 2015). Female veterans are more likely than male veterans to seek mental health treatment (Teich, Ali, Lynch, & Mutter, 2017). Female veterans also have higher retention rates in individual therapy and are 25% more likely to receive sufficient treatment (Doran, Pietrzak, Hoff, & Harpaz-Rotem, 2017).

Veterans' barriers in mental health treatment progression

Estimates suggest that a quarter of service members who enter mental health treatment drop out before completing the recommended number of sessions (Britt, Jennings, Cheung, Pury, & Zinzow, 2015; Hoge et al., 2014). Treatment dropout rates do differ by treatment type, for example treatment for substance use disorders versus PTSD treatment only versus treatment for PTSD and comorbid substance use disorders (Edwards-Stewart et al., 2021; Goetter et al., 2015). For example, in a study of 265 veterans with PTSD, more than 90% of those with scheduled appointments attended at least one session. But dropout rates ranged from 10.3% for group psychotherapy to 18.3% for individual cognitive processing therapy (Browne et al., 2021). Among roughly 60,000 Iraq and Afghanistan veterans with PTSD, less than 10% finished a full course of treatment by 3 years after their first appointment (Maguen et al., 2019).

Veterans describe a range of reasons that contribute to their decisions to drop out of treatment. One common reason is the stigma surrounding mental illness: Veterans cite stigma as a reason for delaying treatment, failing to seek help, or dropping out of treatment once it has begun (Britt et al., 2015; Fox, Smith, & Vogt, 2018; Rodrigues et al., 2014). Veterans also cite a lack of alliance with the clinician and negative beliefs about treatment efficacy as contributors to treatment dropout (Hundt et al., 2020).

They additionally report logistical barriers, such as difficulties with scheduling, transportation, and payment, as well as conflicts with family and work obligations (Browne et al., 2021; Hundt et al., 2020). Finally, some veterans report that therapy is too stressful and that they can handle problems on their own (Hoge et al., 2014; Hundt et al., 2020).

Therapeutic adventure for veterans

Due to veterans' common hesitance to seek mental health treatments in traditional clinical settings, a hesitance that may grow in part from military culture itself, alternative mental health treatments may be useful for this population. Therapeutic adventure interventions that do not look like treatment, but rather look more like outdoor recreation, may be helpful in addressing veterans' mental health symptoms (Bird, 2014).

Even participating in sports and physical activities appears to reduce combat veterans' PTSD symptomology and improve affective experience (Caddick & Smith, 2014; Wheeler et al., 2020). However, studies of veterans who participate in therapeutic adventure interventions, involving such activities as hiking, sailing, and fishing, report reductions in veterans' mental health symptoms after intervention completion (Bettmann, Scheinfeld, Prince, Garland, & Ovrom, 2019; Bird, 2014; Greer & Vin-Raviv, 2019; Marchand et al., 2018; Vella, Milligan, & Bennett, 2013).

Studies of the therapeutic adventure process suggest that several factors are key in accounting for client change among those who participate in therapeutic adventure. Russell and Farnum (2004) suggest that three factors are key: wilderness/nature as restorative environment, physical engagement and challenge, and social support in a cooperative environment. In a study of a therapeutic adventure scale, Russell and Gillis (2017) propose that four factors are critical: group adventure, reflection, nature, and challenge. In a study of process factors in therapeutic adventure outcome, Russell, Gillis, and Kivlighan (2017) found that the factor of group adventure (which includes peer bonding, support from leaders, and experiencing accomplishment) helped to predict positive treatment outcome in one therapeutic adventure program.

Notably, peer-based programs appear to positively affect veterans' help-seeking behavior. For example, research on Buddy-to-buddy, a peer-support program that pairs veteran mentors with service members returning home, found that 50% of participants used resources and services recommended by their peer mentor (Greden et al., 2010). In addition, 20% sought formal mental health treatment following recommendation by their peer mentor (Greden et al., 2010). This finding aligns with other research suggesting that knowing someone closely who has sought professional help increases help-seeking behavior (Disabato, Short, Lameira, Bagley, & Wong, 2018). These findings together suggest that resources suggested by peers during peer-led adventure groups may increase professional help-seeking among veterans.

Greden et al. (2010) also suggest that outdoor programs can act as priming spaces for future change and motivation to engage in later mental health treatment. For example, research on a peer outdoor support therapy program showed that participants commonly reported an increased ability to disclose to others, an increased ability to discuss personal issues, an increased sense of self-determination, and an increased sense of capability and commitment to future change (Bird, 2014).

Therapeutic adventure includes programs that have therapeutic aims but look more like outdoor recreation than traditional clinic-based mental health treatment. Such programs may be useful in addressing veterans' mental health symptoms when internalized stigma against mental health treatment exists. For example, one study showed that veterans with mental illness who participated in a therapeutic adventure program, involving 6-day long wilderness expeditions, also appeared more open to seeking professional psychological help after program participation (Bettmann et al., 2019).

Building upon that existing research, the present study sought to answer the question: Does participation in a therapeutic adventure program correlate with changes in veterans' attitudes toward help-seeking for mental health concerns? If such correlations exist, which demographic or military service-related factors might help explain those patterns of change?

The primary hypothesis for the present study was: Participation in a therapeutic adventure program will correlate with improvement in veterans' attitudes toward help-seeking for mental health concerns. A secondary hypothesis was: Gender differences, disability severity, and deployment status will help explain difference in changes in veterans' attitudes toward help-seeking for mental health concerns. Existing literature suggests that gender differences among veterans do help explain differences in mental health treatment seeking (Fox et al., 2015; Teich et al., 2017), whereas deployment status (combat deployment vs. not) and disability severity predict differences in mental health treatment-seeking differences (Ashley & Brown, 2015; Calhoun, Bosworth, Grambow, Dudley, & Beckham, 2002).

Method

Participants

Participants in the present study were U.S. military veterans who chose to participate in a Sierra Club Military Outdoor therapeutic adventure trip. For the purposes of the present study, military veterans were defined as “a person who served in the active military, naval, air, or space service” (https://www.ecfr.gov/current/title-38/chapter-I/part-3#3.1). Participants were self-identified veterans who were recruited through the Bronx and New York Harbor Healthcare (Manhattan, Queens, and Brooklyn VA facilities) and through the network of New York City university veteran service offices.

Additional participant recruitment was done in a similar manner in Atlanta. Recruitment was done through group email by the participating VA facilities and school veteran support offices. Inclusion criteria were that the adult self-identified as a veteran and attended a Sierra Club Military Outdoor therapeutic adventure trip lasting at least 3 days and 2 nights.

The study collected data from 68 veterans who participated in Sierra Club Military Outdoor therapeutic adventure trips that met the study's inclusion criteria. The final sample included 67 participants who participated in the therapeutic adventure trips because one participant did not complete the primary measure in this study, the Attitudes Toward Seeking Professional Psychological Help scale, at any wave of data collection and was therefore excluded from the analyses.

At baseline, participants reported demographic data and military history. In terms of gender, 56% of the sample identified as male and 18% identified as female. For race/ethnicity, 44% identified as White, 11% as Hispanic/Latino, 9% as Asian American/Pacific Islander, 5% as Black/African American, 2% as Native American, and 5% as other race/ethnicity. For marital status, 23% identified as single, 35% as married, and 17% as widowed/divorced/separated.

For employment status, 27% identified as employed, 29% as retired, 9% as a student, and 9% as unemployed. Respondents indicated an average age of 48.8 (standard deviation [SD] = 14.8) and an average of 9.9 years in the military (SD = 9.4). Respondents indicated an average percentage of service connection of 50.4% (SD = 39.9) with a range of 0–100% connected. Forty-seven percent of respondents indicated ever being deployed. Approximately 15 participants chose not to provide information on demographics or military history.

Procedures

To answer the study questions, the study used a repeated-measures design. Participants in this study, who were both military veteran peer leaders and attendees, completed study measurements pre-trip, immediately post-trip, 1-month post-trip, 6 months post-trip, and 12 months post-trip. Participants in this study attended a Sierra Club Military Outdoors trip that lasted at least 3 days and 2 nights, and included camping. These 15 different trips during the study period (January 2020 to December 2021) utilized varied activities in the outdoors. Some trips involved white-water rafting (46.15% of the sample went on trips in which white-water rafting was the main activity), back-packing (25% of the study sample), kayaking (17.31%), canyoneering (7.69%), and rock-climbing (3.85%).

The Sierra Club Military Outdoors program provides a 3-day long program to train veterans as peer leaders who can recruit and lead other veterans in their own communities into outdoor and natural environments. During the 3-day long Sierra Club training for these veteran peer leaders, veterans receive training on wilderness skills such as traveling safely in natural and wilderness areas, wilderness ethics and skills in line with “leave no trace,” managing first aid and medical issues in wilderness environments, and reducing/managing risk in wilderness settings.

In the same training, veterans learning to be peer leaders were also taught how to practice and teach mindfulness interventions and how to run process groups that encourage veterans to share their feelings on the expeditions.

These nature expeditions were afternoon walks in a city park or days-long wilderness expeditions. For the present study, only participants on Sierra Club Military Outdoors expeditions that lasted at least 3 days and 2 nights, and involved camping were included in the present study. These trips were led by military veteran peer leaders, trained by the Sierra Club specifically.

Peer leaders self-selected to serve in these leadership roles; their qualifications included their veteran status, desire to serve other veterans, and interest in leading nature expeditions. The program administrator for the Sierra Club Military Outdoors program, a veteran himself, provided all of the trainings for the peer leaders. Peer leaders organized their own trips, whereas the program administration for the Sierra Club Military Outdoors program facilitated the internal post-trip assessments. Nine out of 67 participants in the study sample served as a peer leader.

Ethical considerations

All study procedures were reviewed and approved by the University of Utah's Institutional Review Board before data collection. Informed consent was obtained from all participants before participation in the research. No adverse events were reported during the study's data collection. Other outcomes from this study were previously published (Bettmann, Anderson, Makouske, & Hanley, 2021).

Measures

Attitudes Toward Seeking Professional Psychological Help scale—Short Form

The Attitudes Toward Seeking Professional Psychological Help scale—Short Form (ATSPPH) (Fischer & Farina, 1995) is a 10-item scale that is used to examine help-seeking attitudes when experiencing a psychological need. Respondents rate each of 10 statements on a four-point Likert scale from 1 = disagree to 4 = agree. Sample items include: “If I believed I was having a mental breakdown, my first inclination would be to get professional attention” and “The idea of talking about problems with a psychologist strikes me as a poor way to get rid of emotional conflicts.” The ATSPPH has been shown to have acceptable psychometric properties and test–retest reliability (Fischer & Farina, 1995). Reliability estimates for the ATSPPH ranged from 0.863 to 0.927 across the five waves of data collection in the analytic sample (see Table 1).

Table 1.

Descriptive Statistics for Covariates and Outcome Measures in the Analytic Sample (N = 66)

VARIABLES	M (%)	SD	α
Gender
Male	56.1
Female	18.2
Deployment history
Deployed	47.0
Never deployed	25.8
Service connected
Yes, service connected	53.0
No, not service Connected	19.7
Peer leader
Yes, peer leader	13.6
No, not peer leader	77.3
ATSPPH scores
Pre-trip	21.42	6.84	0.90
Post-trip	21.53	6.78	0.86
1-Month follow-up	21.16	7.58	0.93
6-Month follow-up	21.00	6.54	0.90
12-Month follow-up	22.45	7.22	0.92

ATSPPH, Attitudes Toward Seeking Professional Psychological Help scale—Short Form; M, mean; α, Cronbach's alpha; SD, standard deviation.

Covariates

Respondents self-reported their gender, deployment status, VA service connection, and role as a peer leader or trip participant for the upcoming trip at baseline. The VA service connection is an indication of the level of disability that the VA has determined a veteran has, following their time in service (https://va.org/establishing-the-service-connection/). A service connection of 100% indicates the VA system determination that the veteran is fully disabled due to health or mental health conditions and cannot work.

Service connection of 0% indicates the VA system determination that no specific disability pay is warranted for that veteran (https://www.va.gov/opa/publications/benefits_book/benefits_chap02.asp). Each variable was coded as 0 or 1, with the variable name indicating what 1 represented.

Analytic strategy

An initial examination of ATSPPH scores via Wald test did not show a significant difference from pre- to immediate post-trip (Est. = 0.011, p = 0.916). Latent growth curve (LGC) modeling is an application of structural equation modeling (SEM) commonly applied to repeated measures data on a range of psychological and social constructs (Preacher, 2018). The LGC models have shown superior power and performance in detecting linear growth compared with repeated-measures analysis of variance models with fewer required assumptions (Muthén & Curran, 1997).

The advantages of LGC models include efficient estimation in the presence of partially missing data, model assessment via common SEM fit indices, flexibility to estimate trajectories for unequally spaced data points, the ability to estimate variability both within and across people in a single model via latent intercept and slope parameters, and flexible handling of missing data (Preacher, 2018). Given these advantages, LGC modeling was used to examine change in ATSPPH scores over time as well as potential differences in initial ATSPPH scores and rates of change on four theoretically relevant covariates.

However, small sample LGC models may lead to artificially inflated fit indices and convergence issues (McNeish & Harring, 2017). Two LGC models were estimated with Mplus v8.8 (Muthén & Muthén, 2017) using maximum likelihood estimation. The LGC model fit was evaluated via chi-square (χ²) test of model fit, Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), and Root Mean Square Error of Approximation (RMSEA).

Missing data were handled by full information maximum likelihood, and data were missing on 188 out of 594 data possible points. Missing data patterns were analyzed via Little's test of missing completely at random (MCAR) for multivariate data criteria (Little, 1988) and failed to reject the hypothesis of MCAR [χ² (101) = 95.836, p = 0.627]. For each wave of data collection (pre-trip, post-trip, 1-, 6-, and 12-month follow up), 76%, 55%, 48%, 58%, and 61% of participants completed the ATSPPH measure respectively.

Model 1 estimated an unconditional LGC model with a time structure of 0, 0.25, 1.25, 6.25, and 12.25 and showed acceptable model fit [χ² (11) = 15.880, p = 0.146, CFI = 0.972, TLI = 0.975, RMSEA = 0.083]. Model 2 estimated an LGC with the latent intercept and slope regressed on gender, deployment status, service connection, and peer leader status and showed improved model fit [χ² (23) = 22.687, p = 0.479, CFI = 1.000, TLI = 1.000, RMSEA = 0.000]. Residual variance for the final time point was set to 0 in both models given a non-significant, negative residual variance estimate (Dillon, Kumar, & Mulani, 1987).

Sensitivity tests across plausible residual variance estimates for the final time point yielded substantively identical interpretations of LGC estimates and model fit. Sensitivity tests examining service connection as a continuous variable produced substantively identical results to those presented next. For ease of interpretation, service connection was dichotomized before inclusion in Model 2. In addition, separate sensitivity tests excluding both peer leaders and participants who did not report demographic information produced substantively identical results to those presented next. See Figure 1 for a visual depiction of the analytic strategy.

Fig. 1.

Theoretical model of an LGC for ATSPPH over time conditional on gender, deployment status, service connection, and peer leader status. ATSPPH, Attitudes Toward Seeking Professional Psychological Help Scale—Short Form; LGC, latent growth curve.

Results

Details of the analytic sample are reported in Table 1. Full results for both LGC models are presented in Table 2. In Model 1, the latent intercept and slope parameters were significantly different from 0 and varied significantly across participants as indicated by the mean and variance parameters, respectively. The positive and significant latent slope parameter (Est. = 0.125, p = 0.027) suggests that participant scores on the ATSPPH increased from pre-trip to 12-month follow-up. The ATSPPH scores at pre-trip were estimated at 21.012, as indicated by the latent intercept.

Table 2.

Results of Latent Growth Curve Analysis for the Attitudes Toward Seeking Professional Psychological Help Scale

	MODEL 1				MODEL 2
	EST.	SE	STD.	p	EST.	SE	STD.	p
Mean
Intercept	21.012	0.765	3.695	<0.001	24.325	2.373	4.304	<0.001
Slope	0.125	0.057	0.395	0.027	0.568	0.194	1.746	0.003
Variance/residual variance
Intercept	32.334	7.138	1.000	<0.001	26.623	6.316	0.833	<0.001
Slope	0.101	0.032	1.000	0.001	0.074	0.028	0.698	0.007
Covariance
Intercept and slope	0.011	0.373	0.006	0.977	−0.055	0.351	−0.039	0.875
Regression parameters
Male → intercept					−0.413	1.966	−0.032	0.834
Male → slope					−0.370	0.160	−0.505	0.021
Deployed → intercept					−2.261	1.753	−0.191	0.197
Deployed → slope					−0.097	0.127	−0.142	0.444
Service connected → intercept					−2.946	1.833	−0.230	0.108
Service connected → slope					−0.083	0.132	−0.112	0.533
Peer leader → intercept					4.376	2.175	0.273	0.044
Peer leader → slope					−0.026	0.149	−0.028	0.861

N = 66; Est., undstandardized estimate; SE, standard error; Std., standardized estimate.

In Model 2, the addition of covariates for gender, deployment status, service connection, and peer leader status as predictors of the latent intercept and slope parameters showed that scores on the ATSPPH increased significantly more slowly from pre-trip to 12-month follow-up for males compared with females (Est. = −0.413, p = 0.021). In addition, peer leaders indicated significantly higher ATSPPH scores at pre-trip compared with other program participants (Est. = 4.376, p = 0.044).

Significant differences in the latent intercept by gender, deployment status, or service connection were not observed. In addition, significant differences in the latent slope by deployment status, service connection, or peer leader status were not observed. The addition of covariates in Model 2 resulted in a steeper positive slope for ATSPPH scores from pre-trip to 12-month follow-up (Est. = 0.568, p = 0.003), a higher latent intercept (Est. = 24.325), and lower residual variance estimates for both the latent intercept and slope.

In Model 2, both the latent intercept and slope differed significantly across participants. Therefore, after controlling for covariates, ATSPPH scores increased more quickly over time on average. The latent intercept and slope parameters did not significantly covary in either model (see Fig. 1). The covariates collectively explained 16.7% of the variance in the latent intercept and 30.2% of the variance in the latent slope. Figure 2 provides the model estimated scores for the ATSPPH over time by covariate.

Fig. 2.

Model estimated ATSPPH scores over time by gender, deployment status, service connected, and peer leader status. Diff = difference and represents the absolute size of the group differences on the latent intercept and slope for each group after accounting for other covariates; Pr = pre-trip; Pt = post-trip; 1m = 1 month; 6m = 6 months; 12m = 12 months.

Discussion

Results from the present study showed that veterans' openness to seeking professional psychological help increased significantly from pre-therapeutic adventure trip to 12 months post-trip. Findings showed that veterans who attended a 3-day or longer therapeutic adventure expedition increased their openness to seeking professional psychological help slowly over the course of a year after the trip ended. These findings are congruent with the limited previous research in this area. Bettmann et al. (2019) showed that veterans with mental illness who participated in a 6-day Outward Bound wilderness expedition for veterans reported improved openness to seeking professional psychological help from pre-trip to 1-month post-trip.

The present study builds upon that previous research by demonstrating that veterans' openness to seeking professional psychological help not only improved from pre-trip to 1-month post-therapeutic adventure trip, but it also continued to improve in the subsequent 11 months post-trip.

Some previous research suggests that even brief interventions delivered to veterans appear to modify treatment-seeking behavior or intention (Amsalem et al., 2021; Seidman et al., 2018). For example, a randomized control trial of 172 veterans found that those randomized to view a 3-min video of one veteran describing how he was helped by therapy showed greater treatment-seeking intention compared with a control group of veterans (Amsalem et al., 2021). Notably, the female veterans in the video-viewing arm study showed an increase in intention to seek psychological treatment only from pre- to immediately post-intervention, whereas the male veterans in this arm of the study showed an increase in intention to seek psychological treatment from pre-intervention to 14 days post-intervention (Amsalem et al., 2021).

Another study of 74 student veterans found that veterans who participated in a brief self-affirmation intervention and viewed a psychoeducational video reported greater intention to seek counseling a week post-intervention compared with veterans who only viewed the video (Seidman et al., 2018). Thus, the limited research in this area supports the findings of the present study, suggesting that even brief interventions may modify veterans' attitudes toward seeking professional psychological help.

This finding has important implications for veterans' help-seeking and engagement with mental health treatment. Many veterans who need treatment for mental health symptoms or mental illness do not seek it out (Porcari et al., 2017). For example, only-one third of veterans with suicidal ideation receive mental health treatment (Nichter et al., 2021). If participation in therapeutic adventure programs correlates with veterans' increasing openness to seeking professional psychological help, then those seeking to treat and reach veterans might consider creating partnerships with community organizations that already provide veteran-specific therapeutic adventure programs.

Existing therapeutic adventure programs for veterans utilize a range of activities—hiking, fishing, skiing, rock-climbing, sailing, surfing, backpacking, white-water rafting, etc.—which could engage treatment-resistant veterans with a range of ability levels and interests (Bennett, Piatt, & Van Puymbroeck, 2017; Dietrich, Joye, & Garcia, 2015; Dustin, Bricker, Arave, Wall, & Wendt, 2011; Littman et al., 2021; Marchand et al., 2018; Powers, 2020; Rogers, Mallinson, & Peppers, 2014; Sporner et al., 2009). Such interventions might be offered first to veterans who were uninterested or unwilling to engage in traditional mental health treatment in clinic settings.

A systematic review suggests that participating in outdoor recreation, therapeutic adventure, and veteran-specific exercise programs, improves veterans' subjective sense of well-being, active coping skills, mental health symptoms, and positive affective experience (Caddick & Smith, 2014). Given these benefits in help-seeking and psychological health that link to veterans' participation in exercise and therapeutic adventure programs, such programs that work with veterans might increase their impacts by forming partnerships with traditional treatment approaches.

For example, a VA health care clinic might encourage veterans to engage with mental health treatment by first participating in a weekend-long, veteran-specific, outdoor therapeutic adventure program. Such linkages between therapeutic adventure programs and traditional treatment types hold promise for potentially increasing veterans' openness and interest in engaging in such treatment. Given the low rates of treatment-seeking and treatment completion rates among veterans with mental illness (Jakupcak et al., 2013; Maguen et al., 2019), these partnerships may be key in facilitating veterans' treatment engagement.

Importantly, the present study showed differences in the rate of increase in openness to seeking professional psychological help depending upon gender: Increase in openness to seeking professional psychological help was slower for males than for females. The present study's findings regarding gender appear congruent with existing literature on gendered differences in veterans' help-seeking. Specifically, research shows that female veterans are more likely to seek treatment for mental health concerns than male veterans (Teich et al., 2017).

Relatedly, male veterans hold more negative beliefs about both mental health concerns and related treatment than female veterans (Teich et al., 2017). The present study suggests that although therapeutic adventure participation correlates with increased openness to seeking professional psychological help for mental health concerns, this correlation shows up more quickly in female veterans.

The finding suggests that male veterans may face more internal barriers to help-seeking, barriers that therapeutic adventure programs may seek to address. For example, therapeutic adventure programs might consider addressing gendered-differences in help-seeking behavior directly, providing psychoeducation to veteran participants, which places their help-seeking behaviors in a societal context. Veterans may then be less likely to consider challenges in seeking mental health care as their own failings, developing instead an understanding of how societal factors influence help-seeking differentially depending on gender.

Results from the present study also showed significant variability in the starting point and the trajectory of seeking professional psychological help. This finding suggests that veterans may show wide variability in their openness to seeking professional psychological help and may vary significantly in how open they become over time. Some veterans may find it much more difficult to seek professional psychological help, whereas others may find it much easier. Providers of mental health treatment to veterans should be aware of this variability, customizing treatment to the specific needs and openness of each veteran client.

In addition, Figure 2 illuminates group differences in ATSPPH intercepts by service connection and deployment status. However, the present study may have lacked the power to detect these differences statistically. Future research should explore how veterans' openness to seeking professional psychological help may differ by service connection or deployment status, to more appropriately and accurately target interventions to reach vulnerable subpopulations of veterans.

Future research

Findings from the present study should be considered as hypothesis-generating findings, suggesting that future research is needed to establish causality between the studied variables. In the present study, the rate of increase in openness to professional psychological help-seeking was only partially accounted for by the variables of gender, service connection with VA, and deployment status. This finding suggests that other variables, not accounted for in the current dataset, may be responsible for variability in openness to seeking professional psychological help.

Future studies should explore the variables of age, race, ethnicity, and geographic area of residence to investigate whether these help explain cross-sectional and longitudinal assessments of openness to seeking professional psychological help. Existing research suggests that these variables appear to impact help-seeking behaviors (Cheesmond, Davies, & Inder, 2019; Chung & Lin, 1994; Eisenberg, Downs, Golberstein, & Zivin, 2009; Sue, 1994).

In addition, the appropriate dosage of therapeutic adventure for veterans to produce attitudinal change should be explored. Are once a month day-long outings enough of a dose to effect moderate changes in veterans' openness to seeking professional psychological help? How about weekly day-hikes with therapeutic processing? What dosages and what activities, including therapeutic processing, are likely to produce such sought-after changes in veterans' attitudes to seeking professional psychological help? Do therapeutic adventure programs need to take place in wilderness settings or are urban nature environments appropriate?

Do such programs need to be professionally staffed or are peer-trained leaders able to facilitate programs effectively so that attitudinal changes may take place? Such questions surrounding dosage, activity, and staffing should be explored fully in future studies to determine what conditions are necessary to produce meaningful changes in veterans' attitudes toward seeking professional psychological help. In addition, future research should explore differences in ATSPPH scores pre-intervention.

Might such differences pre-intervention have contributed to the findings of the present study? Future research should explore differences in veterans' readiness to seeking professional psychological help by gauging this pre-intervention and then exploring how such variance might correlate with intervention outcomes.

Limitations

Based on the design of this study, the results presented here should be interpreted with caution and a consideration of alternative interpretations of these data. Given the well-established reluctance of veterans to engage with mental health treatment, it is possible that individuals self-selecting into a therapeutic adventure program have more flexible perspectives on openness to seeking professional psychological help. Participants in the present study may be different from other veteran populations, which could limit the generalizability of the current findings.

Second, although the demographics of the sample largely mirror U.S. military veteran demographics (e.g., high percentage of white males in middle adulthood), caution should be taken when generalizing these findings to other racial/ethnic or age groups given the small sample size and lack of broad representation of these groups. Third, without data from a comparison group that did not participate in therapeutic adventure programming, the researchers cannot rule out alternative explanations for the observed increase in openness to seeking professional psychological help.

Multiple scenarios are possible. Participants may have engaged with additional therapeutic providers before or after their participation in adventure programming that altered trends in their perspectives on help-seeking over time. In addition, openness to help-seeking may simply increase over time without intervention, due to veterans becoming further removed from the influence of military culture or as a result of other unmeasured factors. Without additional data, the researchers cannot rule out the possibility that the results presented here are an artifact of selection bias.

To address these limitations, future research should seek to replicate the findings from the present study with large, demographically diverse samples of veterans. Most importantly, the potential impact of any therapeutic adventure program on veterans' openness to help-seeking should be tested via randomized controlled trials.

Conclusion

The present study demonstrated the potential role of therapeutic adventure programs in addressing veterans' help-seeking behaviors. Specifically, results from the present study showed that veterans who attended a therapeutic adventure expedition lasting at least 3 days increased their openness to seeking professional psychological help over the course of a year after the trip ended. The present study has important practice implications for those working with veterans, suggesting a possible role for outdoor and therapeutic adventure programs working in partnership with traditional mental health treatment settings to increase veterans' ability to engage and sustain with needed mental health treatment.

Footnotes

Authors' Contributions

J.E.B.: Conceptualization, investigation, writing—original draft, review, and editing, project administration, funding acquisition; C.C.: Methodology, data curation, analysis, writing, visualization; E.L.: Writing.

Author Note

The data that support the findings of this study are available from the corresponding author upon reasonable request. This study was not preregistered.

Author Disclosure Statement

Grant funding from the Sierra Club supported the data collection for this study. J.E.B., who received the grant funds from the Sierra Club, was not involved in data entry or data analysis. C.C. and E.L. declare that neither of them have financial conflicts of interest for the present study.

Funding Information

Grant funding from the Sierra Club supported the data collection for this study.

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