Psychological First Aid

2019, September/October Adirondac

AS I HAVE WRITTEN MANY TIMES, in decades of leading expeditions into the wilderness ranging from days to months, I have had precious few circumstances calling for more medical knowledge than one would acquire in a basic first aid course. One of the most dramatic incidents I recall was actually a mental health emergency.

While leading a youth group going through a high pass in Montana’s Bob Marshall Wilderness, I was called to look at a 17-year-old who was having severe respiratory distress. The boy had a history of asthma, and had been using his prescription inhaler multiple times because of difficulty breathing. On exam, he was clearly distressed, sweating profusely, breathing rapidly, with a rapid heart rate, and quite anxious. He did not, however, have the characteristic breathing pattern of asthma (prolonged exhalation and wheezing). He was actually experiencing a panic attack, worsened by the medication in his inhaler.

Once it was clear what was happening, it was quite simple to help him. I had him sit down, take off his pack, sip some water, practice regular “mindful” breathing, and relax. I reassured him that he was not having an asthma attack, talked about his concerns, connected to him by holding his hand while talking to him, and in about half an hour he was ready to continue. He did well for the rest of the trip.

I have thought about this incident many times in the years that have followed, and have described it while teaching and lecturing about wilderness medicine. Nothing I did for this kid required any sophisticated first aid technique, yet without intervention the situation could have gone downhill rapidly. Most concerning to me is that very few wilderness first aid courses include meaningful content on psychological first aid.

My experience is hardly novel. Maia Szalavitz’s book, Help at Any Cost (an indictment of the “troubled teen industry”), has some terrifying anecdotes about teens on wilderness expeditions experiencing life-threatening (even fatal) incidents because the expedition leaders did not know how to recognize or address psychological disorders. Many of these leaders were fully trained and certified “wilderness first responders,” or had even more advanced training.

Admirably, some wilderness first aid courses have begun to include material on “psychological first aid.” Unfortunately, much of this content is intended to address the psychological complications of severe injuries, such as PTSD. Indeed, the content and techniques are drawn from the mass casualty literature. While this is important information in some contexts, its applicability to most backcountry travelers is nil. It is further evidence of the disconnect between much “wilderness medicine” and the actual medical needs of wilderness expeditions.

The basics of mental health first aid center around “de-escalation”: Rest, reassurance, demonstrating calm control, regular breathing. Not surprisingly, there are now vendors of structured training in mental health first aid, such as

While there have been very few good studies of the utility of these interventions, this is the unfortunate common denominator for much first aid anyway. Based upon their curriculum, however, the methods seem sound and the content appropriate for leaders of backcountry treks. I know that some New York State youth camps have begun to include similar training for their counselors. As my experience that summer afternoon in the Rockies demonstrated, a mental health emergency in the backcountry is every bit as real and dangerous as an asthma attack.

Tom Welch, M.D., is a physician at Upstate Medical University in Syracuse, New York, and a member of the Wilderness Medical Society. He is a licensed professional guide and Wilderness Education Association instructor, and has guided groups in the Adirondacks, Montana, and Alaska. More information is available on his website,

Download PDF

Topics: General First Aid, Mental Health