Contents lists available at ScienceDirect Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp What are constructive anxiety levels in wilderness therapy? An exploratory pilot study Leiv Einar Gabrielsen a,* , Nevin J. Harper b , Carina Ribe Fernee a a Department for Child and Adolescent Mental Health, Sorlandet Hospital Health Enterprise, Avdeling for barn og unges psykiske helse, Sorlandet Sykehus HF, Postboks 416, 4604, Kristiansand, Norway b School of Child & Youth Care, University of Victoria, P.O. Box 1700, STN CSC, Victoria, BC, V8W 2Y2, Canada ARTICLE INFO Keywords: Day-to-day measurements Friluftsterapi Perceived risk State anxiety Wilderness therapy ABSTRACT Background and purpose: Participant state anxiety in outdoor therapeutic practices continues to raise many questions. To help inform this important topic we present and discuss the results of an exploratory pilot study on participant day-to-day state anxiety throughout a Norwegian wilderness therapy intervention. Materials and methods: Thirty-three adolescents from six groups completed a total of 251 state sections of the State-Trait Anxiety Inventory. Results: On average, there was a slight decrease in state anxiety as the program progressed and a significant reduction in anxiety between the first and final days. The between-subject range was large, and boys reported significantly lower anxiety than did girls. Conclusion: In light of the results, we discuss general understandings of day-to-day state anxiety, gender dif- ferences, group differences, the perception of risk, and the relationship between perceived autonomy and state anxiety. The paper concludes with implications for the outdoor therapy field at large. 1. Introduction The overall purpose of this paper is to explore and consider state anxiety levels in the context of wilderness therapy (WT), an adventure- based therapy treatment modality. We know that participant state an- xiety (i.e., there-and-then) fluctuates as WT interventions unfold, just as we know that subjective levels of anxiety tend to vary considerably among participants in a group. However, how do we navigate these issues so that the treatment offered reaches its full potential and is also provided in an ethically sound manner? We carried out a pilot study in a Norwegian WT program to begin exploring levels of state anxiety reported throughout the treatment process. Rather than attempting to provide answers, this paper aims to discuss what may be considered constructive levels of anxiety in outdoor therapy. Directing the atten- tion to one of the most important psychological states of our WT clients, we hope to lay the groundwork for further discussions and critical re- considerations of this topic. 1.1. Background Anxiety is a complex phenomenon. In this paper, we focus on an- xiety as a fluctuating psychological state rather than a diagnosis. In this sense, anxiety is, as we say in Norway, a two-headed troll. As an emotional state, anxiety can inspire new insights as well as life-af- firming and life-enhancing behavior. However, if the anxiety level in- creases further and remains high over time, then anxiety could become a disruptive problem that poses a major threat to one's psychological well-being [1]. More than a century ago, Yerkes and Dodson [2] de- monstrated the relation between arousal and performance. Perfor- mance increases with arousal but only to a certain level, at which point a further increase in arousal leads to a decrease in performance. This is important, as arousal and worry are the key ingredients of anxiety [3]. As opposed to arousal, worry directly counteracts performance. Worry is understood as a concern regarding what lies ahead; this is in contrast to the type of worry often seen in people who suffer from depression, which tends to focus on the past. Therefore, from these perspectives, one can argue that an effective therapeutic window is reached when arousal is at a medium level and future-oriented worry remains low [4]. Welcoming a certain level of anxiety is also recognized in many classic psychological directions - the essence of these understandings being expressed in the adventure education and therapy literature as the comfort zone model [5]. This model states that personal growth and transformation are most likely to occur in the emotional landscape that lies between comfort and panic. The comfort zone model, and https://doi.org/10.1016/j.ctcp.2019.08.007 Received 23 April 2019; Received in revised form 22 August 2019; Accepted 22 August 2019 * Corresponding author. E-mail addresses: leiv.einar.gabrielsen@sshf.no (L.E. Gabrielsen), njharper@uvic.ca (N.J. Harper), Carina.Fernee@sshf.no (C.R. Fernee). Complementary Therapies in Clinical Practice 37 (2019) 51–57 Available online 22 August 2019 1744-3881/ © 2019 Elsevier Ltd. All rights reserved. T