When a Psychological Emergency Strikes in the Outdoors

Wilderness first aid and first-­responder courses have no industry-wide guidelines when it comes to mental health, and the American Red Cross, which teaches psycho­logical first aid for disaster workers and community-based crisis responders, doesn’t have a course ded­icated to mental health in a wilderness context. But some organizations have started to address the topic. In the United States, that includes the National Outdoor Leadership School, the American Mountain Guides Associ­ation, and Outward Bound. NOLS’s Wilderness Advanced First Aid and Wilderness First Responder courses discuss anxiety, depression, suicidal ideation, and PTSD, says Tod Schimel­pfenig, curriculum director at NOLS Wilderness Medicine in Wyoming, be­cause these are subjects that come up often. “You see the guides and outdoor leaders expressing a need for more training in this area because they’re increasingly having to manage these issues,” he says. 

Baecher, who at five foot five is a compact, fit athlete, with summits of the Eiger and the Matterhorn, among other peaks, agrees. “There are simple things that would be useful in remote environments if you don’t have a psychologist there,” she says. “A lot of the psych courses out there are very urban based.”

To help, she created techniques and ­protocols to teach psychological first aid to people who work and play in the outdoors. She’s uniquely suited to the role. Baecher spent a decade in the Australian army as a captain and psychology officer. In 2016, while still on active duty, she earned a doctorate in psychology, exploring the impact of physical injuries on mental health. Since then she has consulted for elite athletes, corporate leaders, and the Australian special forces, with stints as a military psychologist in Afghanistan and East Timor, while spending her spare time climbing and hiking.

Baecher says that there are some similarities between wilderness expeditions and military operations, like the need to compartmentalize emotionally when exposed to challenging circumstances. Outdoor guides and athletes are also vulnerable to depression and PTSD, either immediately after a harrowing experience or down the road if they don’t process those emotions. “Either they break or they put Band-Aid upon Band-Aid upon Band-Aid, which can lead to long-term psychological issues and affect work, relationships, and daily life,” Baecher says.

For mountaineers, spending time at alti­tude can also strain psychological health. Multiple studies have found that the decrease in oxygen levels at altitude can increase the risk of depression, anxiety, and confusion. One study, done by researchers in the UK, reported hallucinations by 32 percent of climbers above 24,600 feet. And in a Swiss study, seven of eight world-class mountaineers who’d climbed above 27,900 feet without supplemental oxygen reported hallucinatory experiences. 

Malcolm Bass had hallucinations while establishing a difficult new route on Alaska’s 14,573-foot Mount Hunter in 2001. Bass, an alpinist and clinical psychologist from the UK, saw the rocks change shape. He and his climbing partner, Paul Figg, hadn’t slept in 30 hours. Bass remembers looking up at a ridge and seeing talons reaching toward him, as if Mount Hunter were a bird of prey and wanted to consume them. He tried to explain what he was seeing to Figg, who he had begun calling Julian, a partner from a previous climb. Because Bass was aware that hallucinations occur when stressed, exhausted, and isolated in extreme environments, he managed to shake off the confusion and find a safe place to rest, but poor choices at that time could have been life-threatening. “In that kind of terrain, you’re as likely to drag each other off as to save one another,” Bass says. “There are no anchors.”

Whether you’re an amateur or a professional athlete, mental distress in the wilderness is a common experience. “Everywhere I go, I see people who are having trouble coping,” Baecher says. “That includes tough climbers on big mountains.”

Grounded in the neuroscience of fear and her own expertise in the psychology of extreme environments, Baecher’s method features a color-coded tool for assessing a distressed individual in the wilderness, a four-category scale from green (OK to stay put) to yellow (stay put, keep calm) to orange (keep safe and calm, consider evacuation) to red (evacuate). Called the ACCE model­—for assess, communicate, calm, evaluate to evacuate—the approach includes calming techniques, some of which she used on Chris after he witnessed the climber’s fall, such as deep breathing and making concrete plans.

Baecher started working out the specifics for an outdoors-focused mental health training course in April 2018, after taking a wilderness first aid class from a company called Survive First Aid in Sydney. Survive’s training manager at the time, Nathan Burns, is a longtime guide and outdoor educator, a paramedic, and an old friend of Baecher’s. He’d added a section on psychology to the course two years earlier, after hearing from clients about how common mental health issues were in the field and how unprepared they felt to deal with them. In classes, Burns says, he asks who has ever dealt with a fractured femur. “You get one in a hundred who put their hand up,” he says. Next he asks who has experienced some kind of mental health event. “Almost every single person puts their hand up,” he says. “The fact is, every medical or first aid situation has an element of mental health attached to it.”

Baecher first met Burns in 2013 while volunteering for an organization called Backpacker Medics, which Burns founded to send paramedics, hospital workers, and other experts on humanitarian missions around the world. She was enjoying the Survive course and was eager to participate in the psych component. It was more than other outdoor companies in Australia were doing on mental health, Baecher says. But the psych content was based on a curriculum designed to train paramedics working on ambulance crews in urban areas, and in Baecher’s assessment that made it less applicable to wilderness professionals, who usually can’t talk to a supervisor or call for help. Baecher, who laughs easily and says exactly what she thinks, thought there was room for improvement. “I was like, ‘Nathan, can you please let me write this?’ The more research I did, I couldn’t find anything that was relevant for the outdoors.”

To correct this, Baecher looked into published research on a variety of related topics, including mental health first aid, trauma, and risk assessment in the outdoors. She incorporated techniques she’d learned in the military, wilderness first aid protocols, and the mental health continuum, a model for thinking about psychological states as a spectrum, from healthy and coping to injured or ill. Burns collaborated with her, helping develop the color scale, an action plan, and a training module for instruction, along with a memorable acronym. “We brought it all together and mashed it up and drank some wine and finally finished it,” she says. In August 2018, Survive First Aid began incorporating the new approach into its three- and five-day wilderness first aid courses.

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