Psychological
Aspects of Adventure Travel
David
Shlim, MD
Adventure
travel can be emotionally loaded for many people. Traveling
for the purpose of having adventure means placing yourself
into new situations with some uncertainty as to how you
may react. Few people have anxiety about a trip to Hawaii
to lay on the beach, but most people feel some anxiety about
a remote trip to Tibet. Part of the reason for choosing
such an adventure is the hope that the trip itself may change
you in some wayóto make you more aware of your limits, or
to gain confidence by having accomplished something difficult.
The uncertainty of the enterprise, and the absence of standard
emotional supports can lead to the risk of psychological
trauma. This may simply be disappointment in oneís own performance,
or it may lead to a total psychological decompensation.
If the emotional or psychological collapse is severe, the
entire trip will be disrupted, and even getting the person
home will be a severe challenge.
Psychosis
is the term we use to describe people who experience a disconnection
between reality and their perceptions. The same environment
that may help to induce psychosis is fraught with obstacles
that prevent the stabilization of a psychotic person. In
a remote environment there may not be any medications available
for controlling psychosis, and there may be no stable environment
in which someone who is out of touch with reality can be
safely stabilized. Travelers who are not emotionally or
psychologically stable are not allowed on commercial aircraft,
and many evacuation insurance companies specifically exclude
psychological medical emergencies from their coverage.
Even
when psychosis is not a concern, psychological adjustments
are often necessary due to stress on the traveler, prior
expectations of oneís performance in a new environment,
and a feeling of lack of control over oneís surroundings.
The adventurous traveler will be dealing with stress. If
the stress is too severe, there may be some form of decompensation,
or temporary inability to function normally. Other people
may have an exacerbation of underlying feelings of depression,
or may have traveled to try to alleviate a sense of depression
or unhappiness.
Travel
is Stressóand Loss of Control
Even
at the best of times, travel involves a level of stress
that is higher than we usually deal with at home. Depending
on the destination, one has to deal with jet lag, loss of
contact with familiar support systems, bombardment of sights
and sounds, beggars, touts, and people who won't get out
of your face. Even trying to absorb a particularly beautiful
or moving event can be a form of stress. Trying to accomplish
simple tasks, such as finding a decent room, buying a bus
ticket, or obtaining a visa can lead to hours of frustration
and uncertainty. If you are headed to remote areas, you
can have a sense of being too far removed from familiar
surroundings. You may suddenly realize that you are two-weekís
walk from a strange and terrifying capital city, which is
still 36 hours of flying time away from your home environment.
We all
like to think that we can cope with our surroundings. The
heroes that we admire in movies and television all have
in common that they are not flustered by unexpected obstacles.
They just deal with their changing environment as it unfolds,
whether it is a volcano, primitive headhunters, or sleazy
bandits. Most of us try hard to avoid the unexpected, to
exert control over our surroundings, to expect things to
go a certain way. When things don't go as we think they
should, we assume that someone will be able to account for
it, to take responsibility. We extend this concept of control
to most aspects of our existence: we exercise to prolong
our lives and prevent illness, we work hard in the expectation
that we will be rewarded, we avoid areas of cities where
we are likely to encounter trouble, we wear our seat belts.
Weíve "learned the rules" and we think that as long as we
continue to follow them, we can stay out of trouble.
When
one shifts to an environment and culture half way around
the world, these rules can change as well. Michael Palin,
while trying to travel around the world in 80 days without
flying (for a BBC special), summed it up nicely: "What in
Europe had been problems to solve, in Asia became limitations
to accept." One of the most difficult things for travelers
to adjust to is the loss of their sense of control. They
may fall quite ill despite all their efforts to avoid it.
They may find that they bought the wrong ticket; or they
bought the right ticket, but the bus didnít come at all;
or they are on the correct train, but someone else has their
seats. Their trip of a lifetime might be scrubbed by three
days in a row of bad weather, preventing the flight in.
Since we are used to being in control, not having to deal
with situations beyond our control, our stress levels can
reach astronomic proportions.
Further
pressure arises from the concept in the West that we must
assert ourselves when things are not going our way. We are
taught that we should not passively accept events as being
beyond our control. However, in adventure travel, events
may truly be beyond anyoneís control. The successful travelers
are the ones who can learn to accept the limitations and
work within the new systems as they are encountered. What
they ultimately learn is that what we had at home was the
illusion of control. We assumed that we were in control
because things were going our way for a period of time.
But we canít truly prevent illness, accidents, or loss of
friends and relatives. If we think about it, travel just
becomes an accelerated learning course for accepting things
beyond our control. The result of these lessons can be to
become much stronger in dealing with our daily lives at
home.
Personal
Physical Goals
Adventure
travelers often add an artificial stress to their journeys:
the question of whether they will "make it" or not. Adventure
travel is often very goal oriented. Setting out to do something
that you are not sure you can do is part of the adventure.
But linking the attainment of this goal with a psychological
sense of worth can be dangerous. I have seen so many neurotically
anxious people heading out for routine adventures, heedless
of the needs of their traveling companions, oblivious of
the local culture, compulsively monitoring their own health,
all with the goal of standing on some patch of ground that
they have read about.
People
who are planning adventurous journeys should think about
the psychological aspects of finding a balance. They should
train physically to gain confidence in themselves, and so
that they can have more fun. They should realize that it
is truly the journey, not the destination, that will be
their adventure.
Spiritual
Concerns
Travel
to Asia, particularly the Himalayas, seems to have spiritual
connotations for many people. It may be their first genuine
exposure to religion outside their familiar Christian-Judeo
background. They may harbor secret desires to obtain some
spiritual teachings or experience. I believe that the popularity
of Peter Mathiesen's book The Snow Leopard, is based
largely on the fact that he was one of the first writers
about Nepal to confess that he had a secret spiritual agenda.
There is nothing at all wrong with this attitude, if it
is kept in proportion.
The
danger arises when people are traveling in order to undergo
major changes. People who are unhappy at home or feeling
unsuccessful in their lives, may set out to travel in order
to "get it together." The stresses of a new culture, the
sudden exposure to severe poverty, the pantheon of new deities,
and the freedom from normal constraints, may lead to risky
behavior, drug-taking, and psychological dislocation. The
potential for psychological turmoil, even acute psychosis,
is substantial. That is why adventurous travel in exotic
locations may not be indicated for people with a substantial
psychological history of problems. If people who have had
significant psychiatric problems want to start traveling,
it makes sense to first go to destinations that are culturally
more similar to their own, and have some resources to deal
with emotional problems should they occur.
The
use of hallucinogenic drugs in the pursuit of religious
practice in South Asia fueled the beliefs of many Western
travelers that spiritual understanding might follow from
an intoxicated state. Although most stable people can handle
these experiences, drug use can be the final lever into
the abyss of psychosis for some travelers. In addition,
some of the drugs may actually be toxic, or adulterated
with substances that can truly cause difficulties. These
concerns are in addition to the fact that most drug use
by foreigners is highly illegal in most destinations.
Decompensation
Sometimes
travelers are simply overwhelmed by the sights and sounds
and lack of coherence of their environment. The exposure
to what appears to be abject poverty is taken personally,
as if they have to do something themselves to fix it. The
food is perceived as different, unappealing, and unsafe.
The rooms are dirty and noisy. Usually, people gradually
adapt, but they occasionally go home within a few days,
feeling personally defeated.
A gentle
approach can be helpful. You can point out that they donít
have to feel responsible for the unpleasant things that
they are seeing. You can try to get them to question whether
the people they are seeing, who are quite poor, are actually
suffering or unhappy. You can point out that they chose
to travel to see and experience new things, including food
and accommodation. If they canít recover their composure
within a few days, they should either go home, oróless defeatingótravel
to a less intense part of Asia (for example, Thailand).
Panic
Attacks
One
non-psychotic manifestation of stress may be the panic attack.
A panic attack is the name given to a recognizable cluster
of symptoms that often occur without warning. In various
combinations, the person experiences acute chest pain, shortness
of breath, weakness, dizziness, and a sense of not being
able to get enough air. An overwhelming sense of dread is
the hallmark of panic attacks, and the patients often feel
certain that they are going to die. Many patients go to
an emergency room and have a number of tests to rule out
heart attack, pulmonary embolism, pneumonia, asthma, and
so on. All the tests are normal, and the puzzled physician
may simply suggest further tests, leaving the patient feeling
totally anxious. The diagnosis of panic attack is made based
on the clinical presentation of the severe symptoms out
of proportion to any real findings of disease.
Treatment
is based on finding a sympathetic and convincing physician
who can help explain what is going on. In the setting of
travel, this reassurance is often enough to end the cycle
of symptoms leading to a sense of panic. There are specific
drugs that help relieve the anxiety that accompanies panic
attacks.
Most
of the patients experiencing panic attacks cannot pinpoint
a cause. My experience with panic attack patients in Nepal
was that almost all of them had been having a good trip
up to the point of the panic attack. People who had been
nervous and unhappy about traveling almost never had a panic
attack. The tendency to have panic attacks has been shown
to run in families, and the symptoms may not be purely psychological.
The body begins to experience unexplained symptoms, and
the mind appears to react to the body. In any case, knowing
about panic attacks can save days of anxiety in a remote
setting, and avoid the risks of an emergency evacuation.
Psychosis
When
I was working in Nepal I used to go to bed at night hoping
that I would not get a phone call telling me that someone
was acting crazy. There is a wide range of behavior that
is encompassed by the term "going crazy." It may refer to
someone in a near catatonic state, or to a delusional, aggressive,
paranoid person who strikes out at all those around them.
In developing countries, the psychotic patient is often
first encountered in jail, due to their disruptive behavior
in public. The police are only too happy to get rid of someone
who is not in their right mind, unless they killed someone.
When
such a patient is released from jail, or brought to a clinic
by a friend, the goals are to find a stable, safe environment,
with plenty of people to take turns watching the patient,
and to use appropriate amounts of anti-psychotic medication.
Embassies cannot take forceful control of their own citizens
in other countries, so asking the U.S. Embassy Marine guards
to gather up a psychotic 21-year old American man and ship
him home on a cargo plane is not an option. The goal is
to stabilize the patients as quickly as possible, and to
repatriate them, accompanied by reliable people. The value
of
anti-psychotic
medication cannot be overemphasized in this situation. An
injectable anti-psychotic medication should be in every
adventure travel doctorís first aid kit. Hopefully, you
will never need to use it. Droperidol (Inapsine) is a particularly
useful drug to have available for the acutely agitated or
combative psychotic patient. It almost always sedates them
within 20 minutes or so, allowing everyone to catch their
breath and decide on the next course of action, without
four people having to hold the patient down. One can then
start them on either injectable or oral anti-psychotic medications
when the patient becomes arousable again.
The
exact diagnoses in these cases have not been systematically
studied by psychiatrists. The majority of episodes occur
in people with no prior history of mental illness. Acute
situational psychosis is probably the most common diagnosis:
environmental stresses and some personal history combine
to trigger a temporary disconnection with reality. Acute
situational psychosis generally responds very rapidly to
anti-psychotic medication.
Schizophrenia
is a more severe mental disorder that often manifests for
the first time in the late teens or early twenties, a time
when many young people are also traveling abroad for the
first time. A deceptive form of psychosis may be the first
episode of mania, which is part of the diagnosis of bipolar
disease. These people will feel that everything has come
together in their lives, and every event is loaded with
huge meaning. This sense of energy and importance can grow
to psychotic proportions.
Depression
Severe
depression leading to suicide attempts is a very serious
problem among travelers, but fortunately quite rare. These
people may have traveled as one last hope to deal with their
feelings, and when it fails to improve their mood, they
become suicidal. They may have broken up a relationship
while traveling, or failed while trying to work in a volunteer
post. I am aware of a situation in which a disturbed person
mailed a postcard from Seattle as he boarded a plane, telling
his family that he was going to Kathmandu to kill himself.
Luckily, he was found alive in Kathmandu when the American
Embassy searched for him.
The
treatment of severe depression in travelers should be the
same as back home: emotional support, appropriate medication
(particularly if anxiety is playing a large role), and repatriation
with reliable assistance.
Screening
From
the above discussion, one can wonder whether there are ways
to predict who may have psychological problems on a given
trip. There are no systematic studies of people who have
had psychiatric problems while traveling, so we know little
about the past histories of people who had problems, and
whether they could have been recognized in a screening process
as someone likely to have trouble. I would be concerned
about people who have just undergone major life changes:
loss of a lover or spouse, loss of a parent or sibling,
the ending of a relationship, or the loss of a job. For
many people, however, in these situations, travel has truly
had the beneficial and life-reinforcing elements that one
would hope for. So, there appears to be no easy formula
for deciding who should be brought along on an adventurous
trip or not.
I would
be concerned about anyone who has a history of having to
be hospitalized for psychiatric illness. If this were a
recent occurrence, and the person was still on medication,
I would not want an adventurous, difficult trip to a remote
area to be their first travel experience. Even if they are
off medication, one would want to know more about the psychiatric
diagnosis, as many psychiatric conditions, such as schizophrenia
and bipolar disease (formerly manic-depressive disease)
tend to recur over time. In an ideal situation, a person
who has done the trip would be able to interview prospective
clients as to their past travel history and motivation for
going, and get a sense of their general stability and adaptability.
But this type of in-depth interview rarely takes place,
and not all clients are as honest about their past histories
as the adventure travel company would like. Their own doctors
may be completely unfamiliar with the stresses of travel
to certain destinations, and overestimate their patientís
capabilities. For all these reasons, trip leaders and adventure
travel companies should have contingency plans for dealing
with psychiatric problems during a trip. At the very least,
make sure that the clients have evacuation insurance that
does not exclude psychiatric emergencies.
David
Shlim, long-time WMS member, is a travel medicine practitioner,
writer, and researcher. He practiced travel and tropical
medicine for 15 years as director of the CIWEC clinic in
Kathmandu, Nepal. He is currently practicing medicine in
Kelly, Wyoming, USA.
Wilderness
Medicine Letter,
Volume 18, Number 1, Winter 2001
