This story is part of The Aftermath, a Vox series about the collateral health effects of the Covid-19 pandemic in communities around the US. This series is supported in part by the NIHCM Foundation.
In June 2018, a hiker fell to his death in the rugged, forested backcountry near Pratt Lake, about 50 miles east of Seattle. A 22-year-old first responder named Alexis Leader helped recover his body, which lay at the bottom of a cliff, wedged in a snow moat — the gap between a rock face and the snowpack. Leader had been a search-and-rescue volunteer for three years, and while she had assisted with recoveries in the past, this was her first time coming face to face with a dead person.
Leader’s team stayed with the body through the wet and snowy night. Leader cried as she drove out of the woods the next morning.
Later that summer, Leader was hiking with her fiancé and a friend in Washington’s North Cascades. They rappelled over a rocky ledge, unclipped their rope, and prepared to cross a deep moat, similar to the one where she’d recovered the body. The gap looked nearly bottomless and she froze, envisioning herself trapped, cold, wet, and wedged against the rock like the dead hiker. She eventually managed to speak a few words to her companions, control her breathing, and cross the moat.
Backcountry search-and-rescue responders like Leader experience high rates of stress and trauma in their frequently harrowing work. Many missions are, like Leader’s, recoveries of people who have already died a traumatic death, or accompanying a stunned spouse or parent while search dogs dig through the snow for a lost loved one.
The pandemic may have made this kind of trauma even more widespread: Park closures pushed backcountry travelers to more challenging and dangerous terrain, and the 2020-2021 avalanche season killed 37 people in the US, according to the Colorado Avalanche Information Center, making it the deadliest season since detailed records became available. Staffing was meanwhile often tight among responders — early in 2020, some teams pulled older, more experienced rescuers off the job to reduce their exposure to Covid-19.
A few years ago, my colleague Nathalia Dolan and I conducted an anonymous survey of about a dozen avalanche responders and heard stories of quiet struggles with stress, substance abuse, and post-traumatic stress disorder (PTSD). “I think the most unnerving thing was the constant feeling where I was no longer in control of my own emotion,” one responder told us. “I always felt like I was on the edge of holding it together.”
Another put it this way: “Avalanche rescue has been the major contributing factor to me becoming an alcoholic. It’s endemic in the ski patrol culture, unfortunately. Every night after work we’d hit the bars. I didn’t realize how much I was drinking every night to basically numb my feelings instead of managing them.”
In the language of psychiatry, we’d say that many search-and-rescue and disaster response workers experience anxiety, depression, or PTSD. Between 11 and 37 percent of first responders experience PTSD, compared to 7 to 10 percent of the general population. But PTSD can come with a stigma, with some people feeling that it’s their fault they “can’t shake it off.”
That’s why a quiet mental health revolution underway among first responders is so remarkable: Some have come to see their stress-related symptoms as physiologic reactions to difficult experiences — responses more of the body than the mind, exacerbated by fight-or-flight experiences and compounded over months and years. For Leader, understanding the terror on her hike as a biochemically driven stress injury was what eventually allowed her recovery to begin.
It may seem provocative to describe the effects of psychological stress and trauma as physical injuries like sprains and strains. But in my work as an emergency physician and wilderness medicine instructor, I’ve come to believe that in careful balance with other approaches, this idea can help. Meeting people where they are can inspire them to seek support even if they don’t see themselves as a candidate for treatments such as formal psychotherapy or antidepressant medicines.
The first time I heard Laura McGladrey speak, at a Wilderness Medical Society conference in 2018, she compared psychological stress injury to carbon monoxide poisoning that mountaineers can experience while using stoves in their tents — a preventable condition that tends to show symptoms only when it’s become life-threatening.
Stress injuries are physical injuries, she argued, with the same physical symptoms that stress hormones like cortisol can cause, from obesity and diabetes to heart disease and sleep disturbances. If your brain is continually spooked even though you’re physically safe, she says, then the brain secretes more hormones and the body pays the price. “We need to take stress injury formation out of the realms of psychiatry and the psychological,” she told an audience of physicians, nurses, and first responders, “and put it squarely back where it belongs, in the realms of the physical — which is us.”
Glad, as she’s known to friends and colleagues, is a psychiatric nurse practitioner, outdoor educator, and first responder in the Boulder, Colorado, area who has become an icon in the community. Wiry and energetic, McGladrey exudes empathy when she speaks about this new way of thinking about how we deal with acute stress.
McGladrey and others have adopted much of their approach from a military model meant to prevent and identify injuries that could lead to PTSD. More than a decade ago, the US Marine Corps put in place a tool called the stress continuum, which was meant to take a snapshot of Marines’ stress levels. A scale ranging from green (“emotionally and physically healthy”) to red (“relationships and work suffer”) aimed to help individuals assess their mental state and track their stress levels over time.
Rather than use the language of the DSM-5, the handbook that formally defines criteria for psychiatric diagnoses like PTSD and acute stress disorder, McGladrey instead uses the language of physical injury to describe those conditions, which she groups together as stress injuries.
“PTSD is a type of traumatic stress injury, but not the only type,” she told me in an email. She tries to normalize the idea that stress impacts exist on a spectrum, not a binary of either injured or not. When speaking to responder groups, she says, the term “stress injury” removes a stigma and allows stress to be discussed like an occupational hazard, akin to a broken ankle. “Someone should say that the most common injury you’re most likely to experience in your career is stress injury,” McGladrey says. “Not your back, not your knee.”
To complement the self-assessment of the stress continuum, McGladrey recently piloted a system she calls “3-3-3” — basically an informal check-in three days, three weeks, and three months after a significant event. At the three-day mark, the idea is to gauge the mental state of participants at the time of the event and identify some red flags for bad outcomes. These check-ins can also identify people who need more support.
Yuval Neria, a psychologist who directs the PTSD program at the New York State Psychiatric Institute, expresses some suspicion about the “stress injury jargon or metaphor,” sensing a military motivation to downplay the stigma or incidence of PTSD. Nonetheless, he feels that the stress continuum model makes sense from a medical or neuroscience viewpoint. He described a similar strategy to me: simply asking someone how they’re sleeping a few days after an event, and using their response to infer whether they may need more focused interventions.
“There is a window of opportunity … let’s say up to two, three days after the trauma, that you can retrieve the memory and modulate it or play with it, in a way,” Neria says. “Perhaps we [can] make it less associated with guilt and shame and a sense of failure.”
I was intrigued by McGladrey’s approach, but I also wondered if it was naive to hope that relatively minor interventions like a peer check-in or a long hike could fend off the demons of PTSD. McGladrey seemed to be departing radically from a medical model that, for much of modern history, has separated mind and body. I worried that if an injured responder understands their symptoms as the psychic equivalent of a sprained ankle, they may avoid seeking help from those most qualified to offer it. The most deeply injured might never get the help they need.
Many responders favor a biochemical framework for their symptoms partly because it reduces the fear of being labeled “crazy” or “broken.” That fear may look like denial, or hope that time or exercise or peer support could replace the hard work of therapy. Yet while even PTSD can be notoriously tenacious, behavioral treatments like exposure therapy have proven successful. Emerging treatments like guided therapy with psychedelics also hold promise. More broadly, lessons from the first responder community may resonate for all of us in the wake of a seemingly interminable pandemic and the trauma and stress it inflicts on nearly all aspects of our lives.
In April 2001, Bruce Tremper, a longtime staffer at the US Forest Service’s Utah Avalanche Center, published a forecast encouraging travelers to return early from the backcountry because of avalanche risks. The next day, two physicians in their late 30s climbed a slope called Stairs Gulch in Big Cottonwood Canyon. A layer of water had seeped between the snow and the ground, loosening a 700-foot-wide, five-foot-deep avalanche that killed them both. After the slide, Tremper hiked to the site with the father of one of the hikers. “The worst part of it is going [to see] the family — all of them want to know what happened,” he told me.
Tremper worked for more than 30 years in professional avalanche control and wrote a book, Staying Alive in Avalanche Terrain, that remains the gold standard in the field. Yet years later, he found himself getting nervous before giving a talk to a group of first responders. “I was just barely making it through the talk,” he told me. “I felt like I was going to break into tears because every time I would tell a new story, it would bring back those memories again … and at the end of the talk I realized, oh, I need to deal with this.” A psychologist spoke next, about PTSD and psychological injury. Tremper remembers thinking that the speaker was talking about him.
Many search-and-rescue veterans like Tremper grew up in a historically macho, stoic first-responder culture in which you kept your feelings to yourself and moved on to the next mission. Rescuers say they often avoid conversations about how they feel even when they’re depressed, drinking, or experiencing suicidal thoughts — in some cases because they’re afraid to be seen as unfit to work. One responder told me that they didn’t want to risk the same fate as a team member who they said had lost a position after experiencing PTSD-like symptoms.
Psychologists think of stress injury and PTSD as largely about moral injury: In situations where it’s difficult or impossible to follow a moral compass, or where the world conflicts with our sense of right and wrong, a person might feel helplessness, self-blame, shame, or guilt.
First responders’ traditional strategies for addressing (or ignoring) the accumulated injuries have major shortcomings. One approach common in search-and-rescue, post-event debriefing, goes over the technical details of a rescue and aims to expose, acknowledge, and mitigate some of the accompanying psychological fallout. But rescuers told me that many debriefs often wouldn’t get much further than a bunch of beers at the local bar or in the locker room. Mandatory, structured debriefs have their own problems. In the emergency rooms where I’ve worked, I’ve seen a few talkative participants essentially monopolize a session, while less vocal but equally impacted participants may not get a chance to speak.
One problem with group debriefs is they aren’t adapted to individuals. “You bring together people who are very symptomatic with a lot of guilt, or maybe pain, grief, whatever, and you put them in the same room with people who are trying their best to control their emotions and not to be part of this panic,” Neria says. “Then you contaminate everybody with the flow of emotion and anxiety.”
On December 22, 2007, Jake Hutchinson stared out over Canyons ski resort in Park City, Utah, hoping to see whether the terrain was safe for skiing. Hutchinson, then 34, was a former Marine scout sniper who, after 15 years as a ski patroller, was patrol director at the resort and the last word on avalanche safety on the mountain. To reduce avalanche risk by triggering smaller slides, a team had been firing explosives onto the mountain for days, including at the Red Pine Chutes, with a double-diamond run that begins at 10,000 feet.
After examining the layers of snow and considering the weather forecast, Hutchinson made the call to open the slope the next day, confident that the avalanche risk was low. Before heading down the mountain, he skied down the Red Pine Chutes himself, alone.
But on the morning of December 23, a clear day with no new snow and barely any wind, an unseen weak spot gave way, triggering a violent avalanche 125 feet wide and, in some places, five feet deep. The slide overcame an 11-year-old boy, his father, and a 30-year-old from Grand Junction, Colorado. The boy disappeared in the torrent of snow. His father managed to dig himself out uninjured. The 30-year-old struck a tree and was killed instantly.
A dispatcher called Hutchinson’s cellphone with the news. More than 40 minutes after he arrived at the debris field, a volunteer searcher found the boy’s body — buried upright under several feet of snow, skis attached. He had no vital signs. Rescuers started CPR after a few minutes of furious digging, and en route to a hospital, he miraculously regained his pulse and ultimately recovered.
The ordeal sent Hutchinson spiraling. He put himself in risky situations, drinking heavily and recklessly skiing terrain that put him in the path of life-threatening avalanches.
The following spring, the family of the 30-year-old who died in the avalanche filed a wrongful death lawsuit against the Canyons Resort, and Hutchinson was named as a witness. He described his hours on the stand as “some of the most agonizing of my life.” He wondered what could have been done differently. He still wonders why he wasn’t swept away the day before, when he skied the route alone.
Around 2014, Hutchinson woke up on a beach in Baja California, Mexico, exhausted, hungover, and having nearly drowned after swimming into the surf following a long night of drinking. “The guilt of surviving was too much, it still is,” he later wrote in a blog post. He drank, he explained, “not so much to medicate, but more to try and hurt myself, to feel pain so I felt something other than guilt.”
His friends, he wrote, eventually taught him to “stop feeling sorry for myself and focus on what I could learn from all this.” He slowly redirected his self-destructive habits, spending time at the gym and working as an avalanche consultant and search dog handler. Nonetheless, the trauma remained below the surface. He found it difficult to speak openly about making life-or-death decisions, he told me, with people who had never been in similar situations.
Treatment of deep traumas and longstanding symptoms can be more difficult as time passes and exposures accumulate. For some responders, substance use disorders can muddy the waters. But there are effective tools, like psychotherapy or medication, that go well beyond the kind of care that responders might try for a less severe stress injury.
One approach, exposure therapy, aims to reduce symptoms by exposing participants to reminders of their trauma, such as an icy slope or a buried victim. The stimuli can be real, imagined in a therapy session, or even simulated by virtual reality. A recent review of randomized trials showed that patients with PTSD treated with prolonged exposure therapy experienced better outcomes than 86 percent of untreated patients. Several responders told me that they had tried EMDR therapy, which combines exposure therapy, cognitive behavioral therapy, and a series of guided eye movements in order to reprocess traumatic events.
A newer approach involves psychedelic drugs. In a 2021 study published in Nature Medicine, patients with severe PTSD who were given doses of MDMA — ecstasy — in conjunction with therapy sessions reported fewer PTSD symptoms, compared with patients who underwent therapy alone. Other psychedelics, like ketamine and psilocybin, could be promising. A randomized trial of ketamine published last year showed that two-thirds of study subjects had at least a 30 percent reduction in PTSD symptoms after two weeks of treatment.
Last August, in the course of three days, Jake Hutchinson lost two friends to suicide and one to Covid-19. In the wake of those deaths, his drinking accelerated, culminating in a blackout that he still struggles to describe. Twice in 24 hours, he attempted suicide.
In the weeks that followed, he crept out of crisis mode. He stopped drinking and, for the first time since childhood, engaged with formal therapy. Once the alcohol was gone, he told me recently, “I was forced to feel and deal with all these things that I hadn’t.” He began EMDR and cognitive behavioral therapy, which were helping to blunt the PTSD symptoms, but felt that he had to do something else. “I knew I wasn’t going to survive,” he says. “It was going to kill me.”
Hutchinson began guided therapy sessions with both ketamine and MDMA. His initial experience with ketamine, he says, was life-altering. “The first ketamine session,” he told me, “opened my awareness to where the real pain was coming from; the second one opened me up to how to start to forgive myself and work past it.” He considers the MDMA-guided therapy even more profound.
In Hutchinson’s telling, the psychedelics helped him remove a barrier to self-analysis, maybe creating a better understanding of how he’s processed — or not processed — years of personal and professional trauma. Since then, Hutchinson has been vocal about his experience, and finds that younger responders now approach him to talk about their own traumas.
In addition to treatments, we need tools for prevention. So far, little evidence supports the effectiveness of any program to prevent stress injury, or even identify who is most at risk of PTSD. Virtual reality, which is effective in both medical and military training, may help prepare responders by exposing them to provocative stimuli in a safe setting and then coaching them through adaptive responses. But on a more immediate level, rescue teams have been implementing their own frontline systems to mitigate psychological harm before the real damage is done.
In 2012, Mike Moyer climbed into a helicopter in Jackson, Wyoming, and set out with two colleagues to the site of a fatal snowmobile accident. He had been volunteering for an elite Teton County search-and-rescue team since the 1990s, but what happened next was still a shock. On the way to the site, the helicopter entered a spin, lost altitude, and landed upside-down among thick trees. Moyer was severely injured, but he pulled his colleague Ray Shriver and pilot Ken Johnson from the wreckage. Shriver died at the scene later that day.
“What helped me personally get through losing Ray, and taking care of him as he died, was knowing that what I was experiencing in those following weeks and months was normal, and I wasn’t crazy, and I wasn’t weak,” Moyer told me. When thinking about taking more pain pills or experiencing a flashback while driving, he reminded himself that his reactions were expected. “My logical side and my emotional side could reconcile and come to agreement,” he explained. Moyer credits years of stress training presentations for his ability to work through those reactions.
At the time, Stephanie Thomas was a colleague of Moyer and Shriver, serving as executive director of the Teton County Search and Rescue Foundation. She wasn’t on the helicopter that day, but the crash had an impact on her, and years later, preparing to board a helicopter for a backcountry rescue, she froze. This is the most dangerous thing I can do right now, Thomas thought.
“I was just like, what the heck am I doing? I have a 4-month-old at home,” she told me. “I basically had an anxiety attack.” Thomas eventually managed to talk herself through the experience, get on the helicopter, and help rescue a critically injured patient. But she needed to take a step back. She talked to the organization’s leadership at the time and felt the response was dismissive, along the lines of, “Yeah, everybody has those days.”
Over the years, Thomas has referenced that experience to champion a proactive approach to mental health care that, in my view, builds on and significantly expands the “stress injury” model. A volunteer’s death by suicide, in 2015, also spurred the Teton County group to get serious about awareness and treatment.
Thomas came to understand that part of the mental toll was not from the danger of the rescue, but from the feeling of helplessness with loved ones who had just lost someone in a deadly incident. “I’ve responded to a number of cases where I’m standing on the side of the road with a guy who’s just lost his brother,” Thomas told me. “Instead of having some sort of program where I have the number to call, for somebody to offer him care and next steps, I basically hand him his car keys and he drives to his hotel room.”
That anxiety and discomfort, Thomas believes, causes collateral damage to the responders. What keeps rescuers up at night, she told me, “wasn’t the guy who was dead under the snow. It was the guy standing next to him who was trying to revive him for two hours before we got there.”
Seven local agencies now work together to coordinate mental health support for responders in Teton County. A group of therapists communicates on WhatsApp and organizes check-ins and focused treatment for responders in near real-time. Peers and professionals reach out to responders after — and even during — traumatic events. The agencies have capitalized on the model advocated by McGladrey and her colleagues, with a substantial focus on prevention. Last year, the organizations offered every team member a wellness check with a local therapist, and two-thirds of the responders participated.
The next step, Thomas says, is to partner with the family members of rescuers — spouses and children who can provide their own emotional support and detect the first signs of worsening anxiety, depression, or substance use. All of these efforts, she says, combine to help people do their jobs safely and feel better. In the global emergency of the Covid-19 pandemic, when almost everyone has experienced loss or struggle, I have to wonder whether the rest of us could benefit from these same lessons.
“You can’t make good decisions if you’re at an elevated stress response,” she told me, using language that Alexis Leader and Laura McGladrey might find resonant. “If we figure out ways to lower people’s stress responses, they can do their jobs better.”
Christopher Tedeschi is an associate professor of emergency medicine at Columbia University. He writes about wilderness and disaster medicine.
Editors: Eliza Barclay, Daniel A. Gross
Photo editor: Bita Honarvar
Copy editors: Kim Eggleston, Caitlin PenzeyMoog, Tim Williams
Fact-checker: Willa Plank