They came for 16-year-old Kayla Freilich at 3 in the morning, taking the groggy teenager from her home two years ago, when her resistance was weakest, and putting her on an airplane bound for the remote mountains of Oregon.
Freilich had been struggling with panic attacks, depression, self-harm, and an eating disorder, but had resisted most treatment. And then came a suicide attempt. Desperate for answers, her frightened parents enrolled her in 11 weeks of “wilderness therapy,’’ a program that routinely entails transporting defiant teens in the middle of the night.
“We were lost,’’ said her mother, Erica Freilich, whose daughter now attends Boston University “It was either do this or watch your child die.’’
Her family’s health insurer, however, would not cover the $500-plus daily cost of wilderness therapy, which was once considered medicallysuspect, but now is slowly gaining acceptance as programs strive to improve safety and effectiveness. Instead, the Freilichs were forced to deplete college savings to pay for their daughter’s care.
Now, a growing number of families are challenging insurance companies that refuse to cover wilderness therapy, including a Massachusetts family that sued Harvard Pilgrim Health Care in May for refusing to pay for their son’s therapy at RedCliff Ascent, an outdoor behavioral therapy program in Utah. His mother wound up covering the $16,005 cost of treating his oppositional defiant disorder, substance use disorder, depression, and low self-esteem, the lawsuit says.
Another family filed suit against Blue Cross Blue Shield of Massachusetts last fall for denying coverage for their daughter to attend Evoke Therapy, the program in Oregon and Utah that Freilich completed, to treat depression, low self-esteem, suicidal thoughts, and drug use.
Lawsuits have been filed in Florida, Kentucky,New York, and Utah, bolstered by federal rules expanding mental health care coverage, and by improvements in the wilderness therapy industry itself, which had been heavily criticized following a series of deaths a decade ago.
The adolescents who turn to wilderness therapy “are on the brink,’’ said Patrick Sheehan, a Boston attorney who filed many of the lawsuits. “It is a life-or-death choice for them.’’
The two Massachusetts insurers named in recent lawsuits would not comment on why they don’t cover wilderness therapy. But other companies have argued that this approach is experimental, and without proven benefit.
Brad Reedy, a psychologist and co-owner of Evoke, describes the benefits this way: Teens spend four to five days a week hiking, and have daily academic, reading, and written therapy assignments. As at many residential mental health facilities, they receive one or two group therapy sessions each day. A psychologist or social worker travels to the campsite once a week to provide individual therapy and run two group sessions.
Unlike residential therapy, wilderness programs strip away everyday distractionsby requiring participants to live for weeks in the woods, mountains, or desert, where, surrounded by nature, teens can more easily contemplate their struggles and decide how to work on them, proponents say.
“I didn’t see the inside of a building for 11 weeks,’’ said Kayla Freilich in an interview. “It ended up being really serene for me.’’
Evoke, which runs a separate program for adults, takes “teens and young adults with every mental health issue and addiction issue there is,’’ Reedy said. The company draws the line, however, at those with acute eating disorders — they might be too weak to hike — or who are actively psychotic or suicidal.
A medical doctor evaluates participants when they arrive, and a psychiatrist is always available, Reedy said.
Evoke has never had a participant die in the wilderness, Reedy said. But these types of safeguards at programs in part grew out of serious safety lapses at a handful of companies. In a 2007 report, the Government Accountability Office documented the deaths of 10 teens who attended wilderness therapy or boot camps between 1990 and 2004.
Eight died at wilderness programs from causes that included dehydration, heat stroke, acute infection from a perforated ulcer, and a severed neck artery. In the last case, staff had restrained a boy for 45 minutes, holding him face down on the ground. In another case, a Massachusetts boy, 14, hanged himself in his tent while enrolled in a program that did not have a suicide prevention plan.
The GAO also found that staff were often not trained to recognize treatable illnesses, believing teens were faking symptoms to escape rigorous hikes.
Since then, the industry has made dramatic changes, said Michael Gass, a professor at the University of New Hampshire in kinesiology — the study of human movement — who researches the effectiveness of wilderness therapy.
The Outdoor Behavioral Healthcare Council now accredits programs as a way to improve standards, and several states, including Utah and Oregon, license them. Proponents of wilderness therapy successfully lobbied a national organization that establishes billing codes for insurance companies to come up with a code for wilderness therapy. That will take effect July 1 and will make it easier for programs to bill insurers for their services, though it doesn’t necessarily mean insurance companies will pay.
“The field has evolved,’’ said Will White, a social worker who cofounded Summit Achievement in Stow, Maine. “You are working with kids and families in crisis. They are out in the wilderness at times and that can be risky. But locked facilities can be risky too.’’
Although some studies suggest that teenagers enrolled in wilderness therapy show moderate improvement in self-esteem, behavior, and social skills, many psychologists still think the evidence is inconclusive.
Spending time in nature does seem to contribute to better health, said Jennifer Warkentin, director of professional affairs for the Massachusetts Psychological Association. But she said that does not mean that being in the wilderness is thekeycomponent to a treatment program.
“If you take out the therapy, does being in wilderness by itself do it? It doesn’t,’’ she said.
“Many would say you have to have a quality treatment program; whether it’s taking place in the wilderness and or in a group home doesn’t matter.’’
The lack of conclusive research may be one reason insurers have excluded wilderness therapy from mental health coverage.
But Mary Covington, president of Denials Management, Inc., a Utah company that appeals insurance company denials, said she is winning more of these fights, in large part due to 2013 federal rules requiring coverage of “intermediate care’’ for patients.
“That opened up everything for wilderness therapy,’’ she said. If the insurer covers skilled nursing or inpatient rehabilitation on the medical side, then, she argues, they should cover intermediate treatment on the mental health side.
Erica Freilich was so worried about her daughter that the lack of insurance coverage did not deter her. Kayla is the youngest of four children, and had struggled for years with mental health issues but refused to engage with therapists. One eventually recommended that the family hire an educational consultant to research options.
“We had never heard of wilderness therapy,’’ Erica Freilich said.
Evoke recommended middle-of-the-night transport in case Kayla refused to go. Her parents were told they should be prepared to say goodbye to their daughter and then leave her alone in their New Jersey home. But Kayla, who had insomnia and was watching television when her two transport team members arrived, went willingly. They reassured her about the program and texted her parents updates on Kayla’s journey.
Kayla said that hiking 4 miles a day with a full backpack was exhausting, but she loved it. “They give you a set amount of time to pack up your shelter tarps. At first I was terrible at it and then I became a shelter master,’’ she said.
At one point two girls in her group fought, giving Kayla “an insane amount of anxiety’’ and sending her into a “somewhat dissociative state,’’ she said. She slowly began walking away, following a stream. Eventually, staff called her name and she headed back. She was put on “run watch” for three days, sleeping between two counselors and giving up her boots, wearing Crocs instead, which are harder to run in.
If it hadn’t been for wilderness therapy making her more open to treatment, Kayla doesn’t think she would have agreed to residential care afterward. Kayla, now 18 and feeling better, is working as a camp counselor this summer. She will be a sophomore at Boston University in the fall.
“One of the things this program showed her is that there are people like her; your siblings are not the only basis of comparison,’’ her mother said. Afterward, “in the car the first thing she said to me was ‘Thank you for sending me there. You saved my life.’’’Liz Kowalczyk can be reached at firstname.lastname@example.org.