Can wilderness adventure repair the ravages of war?
By Reed McManus
"A year and a half after returning stateside I still had nightmares. I'd go five or six days without sleep. I had the shakes when I entered a shopping mall. That's when I realized I couldn't just tough it out, I couldn't fix it myself."
Those are the words of a former U.S. Army medic, a veteran of what are euphemistically called "mass casualties" in Fallujah and Najaf, Iraq. He's asked to remain anonymous for reasons of job security: No matter how sympathetic employers may appear to be, he says, once they learn of the severity and rigors of post-traumatic stress disorder symptoms and treatment, a "we'll tolerate it as long as it's not disruptive" caveat tends to kick in. But his recollections of nightmares, shakes, and sleeplessness are so common that they could have been spoken by any of the approximately 300,000 vets who have PTSD. The illness afflicts some 20 percent of returning military personnel and up to a third of those returning from multiple deployments.
Since 2008, the Sierra Club's Military Families Outdoors program has offered free trips, through Outward Bound's Veterans Expeditions, to veterans who have served in the Gulf, Somalia, Iraq, or Afghanistan wars. The program makes no therapeutic claims; it just promises "adventure and challenge, solitude and reflection." But any wilderness lover can regale you with stories about the long-term calming effects of an outdoor trek. If a mountain expedition provides mental floss for your average harried urban desk jockey, wouldn't it help someone grappling with the memories of war?
The answer is as untidy as PTSD is complicated. "We know that wilderness heals. We just don't know if it heals PTSD," says Dr. Matthew Friedman, executive director of the U.S. Department of Veterans Affairs' National Center for Post-Traumatic Stress Disorder and himself a veteran of several Outward Bound treks.
Therapies vying to become VA-approved treatments must meet the gold standard of surviving peer-reviewed randomized clinical trials, and no outdoor-adventure program has been put to that test. (The VA's first-line treatments include psychotherapy and antidepressants.) But, Friedman adds, even if outdoor activities don't specifically ameliorate PTSD, they may reduce the stress that hinders PTSD recovery. VA facilities across the country incorporate exercise and outdoor activity into some of their PTSD treatment programs, prompted by anecdotal evidence from those who know the disorder best—the vets who struggle with it every day.
"When I showed up at the Veterans Center, it was the first time I'd ever spoken to anyone about PTSD," the Army medic says. "My one hope was that they'd tell me I didn't need to be there."
To try to understand PTSD, magnify what you know about everyday stress by 1,000. In the simplest terms, a PTSD sufferer "is someone whose life has been dramatically changed after exposure to a catastrophic event," Friedman says. The experience alters how the patient's brain processes information, how he or she reacts to the environment, and how he or she behaves with loved ones and strangers. The sufferer becomes intensely preoccupied with the triggering event—whether it's being involved in or being a first responder to a military attack, a childhood trauma, or domestic violence. The symptoms can last years or a lifetime. Some researchers believe symptoms can recur late in life even after seemingly successful treatment.
PTSD rewires the amygdala, an almond-shaped mass of nuclei in the center of the brain that processes highly charged emotions like anger, fear, and pleasure. It determines what memories the brain stores and where it stores them. "It's the ignition switch for human stress response," Friedman says. Complicating matters, mechanisms in the frontal cortex that typically bring the amygdala back to normal levels are unable to do so in PTSD patients; their brain scans show a hyperaroused amygdala and an underactive prefrontal cortex. The combination creates what Friedman calls "a perfect storm."
Those with PTSD are good at perceiving danger but not at understanding when a danger is in the past. The soldier returns to a life that may be comfortable but mundane. Accustomed to adrenaline-fueled life in a war zone, a vet with PTSD is hypervigilant and unable to cope with the traumatic recollections that flood his or her mind. Family members rarely know how to react to someone whose sense of life and death was formed under such stress, furthering the vet's sense of alienation. It's no surprise that a majority of those with the disorder have comorbidity issues like alcohol and drug abuse. "PTSD rarely occurs in isolation," Friedman says.
Outdoor activity sounds like it could be the perfect antidote. The mental health benefits of a wilderness adventure are familiar to Sierra readers: You're in beautiful country, away from everyday stressors (from coworkers to family members to cell phones), and focusing on your simplest needs—eating, sleeping, putting one foot in front of the other.
The physical challenges of high-intensity activities like climbing and mountain biking are particularly helpful in building self-confidence, says Chris Read, program director of the Adaptive Sports Center in Crested Butte, Colorado, which works with vets from around the country. "You have to be committed in a challenging outdoor activity," he says. "The vets learn they still have the confidence to go outside their comfort zone, and do it successfully. That opens the door to other possibilities for them." Read says that ice climbing is one of his organization's most successful activities for vets because its "perceived challenge" is so high. On the quieter end of the spectrum is Nordic skiing, which provides a solitude that vets may rarely experience. "Introducing healthy leisure interests is critical and makes a huge difference over the long term," Read says. "If a vet returns home to Omaha and goes for a bike ride or a run instead of bellying up to a bar for three hours, the ripple effect is huge."
"It felt good to get back to something that was good before the war," the Army medic says."
The key seems to be helping vets experience intense challenges free from the psychological shackles of life-and-death danger. "For these guys, hypervigilance is a way of life," says Outward Bound instructor Bob Dawes, a Vietnam vet still dealing with his own PTSD. "They've learned that someone will die if things aren't done perfectly. Their head is on a swivel." Read looks for "flow experiences"—all-encompassing activities that help vets lose track of time. Downhill mountain biking is more than thrilling, he says. "It reintroduces vets to what it's like to not be constantly reminded of issues they struggle with on a daily basis. Once you've settled into a rhythm, your brain can relax and wander."
One novel theory suggests that rhythmic outdoor activities like hiking, running, cycling, and Nordic skiing may have direct therapeutic benefit for those with PTSD. The theory is based on a VA-recognized treatment called eye movement desensitization and reprocessing. In EMDR therapy, the patient focuses on a repetitively moving object or flashing light, to make recollections from short-term memory easier to process. Barbe Chambliss, a therapist in Carbondale, Colorado, admits that equating outdoor activities to EMDR effects is conjectural, but notes that therapists have had success using rhythmic outdoor activities when treating kids with attention-deficit/hyperactivity disorder.
"Any activity that works like EMDR would tend to do the same thing," she says. (A recent study by the Minneapolis Veterans Affairs Medical Center and the University of Minnesota found that PTSD patients exhibited hyperactive communication between the temporal cortex—where those past experiences fester—and two other areas on the right side of the brain.) The VA's Friedman suggests that a repetitive motor movement like cycling or skiing may simply reduce stress.
Specific measures aside, Outward Bound's Dawes says that "the most healing occurs while [people are] drinking coffee and hanging out by the river" with fellow vets. "They realize, 'Hey, I'm not the only one who feels this way.'"
Group cohesion on wilderness trips is particularly important. "It was one place I was able to interact socially with other vets," says the Army medic. "Most civilians have put Iraq and Afghanistan behind them." In fact, he says, it was especially helpful for a group of vets to turn the tables on the nonmilitary instructors, asking them how they felt about the military and combat.
One of Dawes's trip participants struggled with Outward Bound's "journaling" exercises. It was something he hadn't done since he'd been in Afghanistan, he told Dawes. By the end of the trip, though, he was comfortable and communicating his concerns. Another vet told Dawes he couldn't relax or sleep—until he came on the trip.
For those with military experience, organized outdoor excursions have other benefits. Such a trip is familiar terrain: Like a military unit, it's regimented, and the instructors take care to make clear what is going to happen and what everyone's position is. A lot of the requisite skills are things the vets learned in the military, like map reading and rappelling.
"It helps them learn that their military experience is a positive part of their life experience," Dawes says. "They learn they just need to deal with it differently. Otherwise, you become a victim, prone to isolation and authority issues." Just putting themselves into a position of hardship—but without the constant danger—changes vets' perceptions. In 2004, Dawes hesitated to sign on to his first trip through the Denver Veterans Center. He figured he'd experienced enough adversity in the outdoors. "I swore I was never going to put myself in that situation again," he says. But he became hooked and has led nearly 20 trips since.
Dawes likes to hold "remembrance ceremonies" on his trips. If all the participants are willing, the group will gather at some point late in the expedition to pay respect to friends who died in war. It was during one such ceremony, on 13,000-foot-high Virginia Peak in Colorado, that Iraq vet Jonathan McMaster—who had seen bloodshed not only as a Marine Corps radio operator in Fallujah in 2004 but also as a freshman at Colorado's Columbine High School in 1999—had "clarity of thought." "It really brought home the point that there were other people who had sacrificed," he told the Army Times. "I recommitted myself to living vigorously for the dreams and goals I wanted to pursue." McMaster is now an economics student at Yale, currently participating in an exchange program at Oxford University.
Still, there are risks in putting people prone to stress in a potentially stressful situation. Dawes tells a story of a 22-year-old vet who struggled on a "short solo," in which participants stay in one spot alone overnight. "It was too quiet," the vet reported, "like right before a mortar falls." (He almost left the program at that point, but he chose to stick with it after talking with the instructors.) Another confronted his anxieties on a rappelling course. "He couldn't lean out and trust the rope," Dawes says. Trust issues are common triggers, says the VA's Friedman. "If a vet believes, erroneously or not, that his commanding officer led him into an ambush, that can translate into mistrust of authority."
One size does not fit all. "You need to recognize when people need to be pushed and when they need to be supported," Dawes says. Outward Bound instructors are trained to spot PTSD symptoms, especially since they see more undiagnosed cases than diagnosed ones, according to Dawes. He introduces himself to participants by phone before the trip, and he or another instructor has a "sit-down" with each participant three days in. The instructors check in with each other nightly and compare notes. They use subtle prompting to get participants to open up. "We engage in conversation, without intervening," says Dawes. "It's about building trust and rapport." If he suspects a trip member has undiagnosed PTSD, Dawes may suggest that he or she seek help from the VA.
Even though the vets hang out together, Dawes notes that they may not ask tough questions about each other: "We'll pose a question like 'What is going really well right now?' and then step off." The key is to turn the trip into a "transferable experience," he says. "At trip's end, we may ask, 'What did you feel here that you'd like to continue when you return home?' We want them to summarize the experience for themselves."
A week or two of blissful, challenging recreation in God's country won't cure PTSD. "The war never disappears," as the Army medic puts it. But the VA's Friedman is quick to point out that "we all return from an outdoor activity feeling better about ourselves, our world, and our colleagues." It's something that Dawes sums up simply: "The magic is the whole thing."
REED McMANUS is a senior editor at Sierra.
This article was funded by the Sierra Club's Military Families Outdoors program.
Photo by iStockphoto/by_nicholas