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Psychological First Aid


Edward M. Kantor, M.D.
David R. Beckert, M.D.

Dr. Hardy, a private practice psychiatrist in Charleston, South Carolina,


heard about the Haiti earthquake on the news one evening in January 2010.
A volunteer paramedic prior to medical school, he reflected on his past
emergency experience and decided he might be of some use in the relief ef-
fort. During his initial Internet search, he came across a journal article on the
mental health needs after major disasters such as earthquakes and hurri-
canes. He wasnt sure where to start, and was concerned that he didnt speak
Creole or know much about the Haitian culture, but he was healthy and
willing, so he decided to figure out how best to get involved. After an ex-
tensive Web search, he realized he lacked any specific training or experience
in disaster mental health interventions, such as Psychological First Aid, as
suggested by most of the U.S. and international response agencies.

Major response agencies and training groups recommend Psychologi-


cal First Aid (PFA) for use in early response to the emotional needs of those
affected by disaster and major traumatic events (Hobfoll et al. 2009; Na-
tional Institute of Mental Health 2002; Ng and Kantor 2010). The core
elements of PFA are contact and engagement, safety and comfort, stabili-
zation, information gathering, practical assistance, connection with social
supports, information on coping, and linkage with collaborative services.
PFA has great merit and promises to reduce variations in the approach to
early intervention as it evolves into the standard tool for mental health pro-
fessionals and first responders alike.
In this chapter we outline the history and evolution of PFA, describe
the goals and basic elements that inform its implementation, and review
key components and resources for intervention with specific populations.
203
204 DISASTER PSYCHIATRY: READINESS, EVALUATION, AND TREATMENT

History and Evolution


After 9/11, early mental health interventions for disaster survivors re-
ceived increased attention. Federal support for disaster response planning
required that states address mental health issues to receive funding. Al-
though sources vary in reporting its origin, PFA, as a basic concept, is not
new in the psychological literature. In the military and civilian response
communities, various forms of Critical Incident Stress Debriefing (CISD)
formerly prevailed as the primary intervention for police, fire, and emer-
gency medical services workers, even as late as 2005 (McEvoy 2005). Oth-
erwise, a great variety of approaches were used by unaffiliated mental
health responders, who applied their individual or group early treatment of
choice to victims of disaster. As a result of several expert consensus confer-
ences and literature reviews (National Institute of Mental Health 2002), it
became clear that components of psychological debriefing, such as CISD,
could worsen stress symptoms in some people and did not appear to pre-
vent the posttraumatic psychological effects of disasters. (Psychological de-
briefing is distinct from operational debriefing, which is used to evaluate
organizational effectiveness and learn about what worked and what might
be improved.)
Although the evidence is still evolving, it appears that early interven-
tions that reconnect victims with family, social supports, and known re-
sources may prove to be the most effective in facilitating recovery (Hobfoll
et al. 2009; Orner et al. 2006). At its essence, PFA is an attempt to attune
to the specific human needs and emotional style of the individual and his or
her expressed needs at the moment of intervention. It emphasizes em-
pathic listening coupled with nonjudgmental responses, as well as an at-
tempt to support individual coping styles and connect the individual to
helpful social supports.
The roots of PFA can be found in the evolving literature of crisis inter-
vention and traumatic stress. As far back as the 1950s, a special article in the
Journal of the American Medical Association titled Psychological First Aid
in Community Disasters (Drayer et al. 1954), written by the American
Psychiatric Association Committee on Civil Defense (forerunner of the as-
sociations Committee on Psychiatric Dimensions of Disaster), outlined
many of the basic premises used in more formal PFA training. Twenty years
later, Beverly Raphael (1977) used the term and added some basic ap-
proaches to bereavement intervention. Much of the recent disaster litera-
ture continues to support interventions and objectives, as outlined in Table
121, that promote safety, help to return a sense of control, and link indi-
viduals to relevant supports in the community or to people or institutions
of particular significance to the survivor (Orner et al. 2006).
PSYCHOLOGICAL FIRST AID 205

TABLE 121. Basic objectives of Psychological First Aid


Establish human connection in nonintrusive, compassionate manner.
Enhance immediate and ongoing safety and provide physical and emotional support.
Calm and orient emotionally overwhelmed and distraught survivors.
Help articulate immediate needs and concerns; gather information as appropriate.
Offer practical assistance and information to address needs.
Connect survivors with relevant support networks, family, friends, and helping
resources.
Support positive coping and empower survivors to take an active role in recovery.
Provide information to help cope with psychological impact of disasters.
Facilitate continuity and ensure linking to other sources of support when leaving.
Source. Adapted from Brymer et al. 2006.

The Developing Standard


In the United States, Psychological First Aid often refers to a very spe-
cific, organized approach for mental health workers to use in responding to
disaster survivors, developed through the National Child Traumatic Stress
Network (NCTSN) and the National Center for PTSD (NCPTSD). From
what was previously a generic term for these basic interventions, a semi-
structured field guide has evolved for use by mental health providers who
are well trained in their basic practice but not in crisis and disaster work.
PFA guidelines emerged as evidence accumulated against the use of psy-
chological debriefing due to its potential for worsening symptoms and in-
creasing the risk of developing posttraumatic stress disorder (PTSD) (see
Chapter 13, Group and Family Interventions, and Chapter 14, Psycho-
therapies). Those findings and the lack of alternate safe practices have ce-
mented PFA concepts into general use. NCCTS and NCPTSD released the
first edition of the PFA Field Operations Guide immediately after Hurri-
cane Katrina (Brymer et al. 2005). This was revised to accommodate new
materials and information, and a second edition was released in 2006 (Bry-
mer et al. 2006). A later version of the field guidePFA for Medical Re-
serve Corpsresulted from collaboration of NCTSN with the Civilian
Volunteer Medical Reserve Corps (MRC) National Mental Health Work
Group (Brymer et al. 2008). The widespread dissemination of the PFA
Field Operations Guide, including its eventual adoption by the American
Red Cross for an updated mental health training course, further supported
its acceptance by public health agencies, the military, and state and local
governments (National Child Traumatic Stress Network 2009).
206 DISASTER PSYCHIATRY: READINESS, EVALUATION, AND TREATMENT

The PFA Field Operations Guide attempts to utilize the available liter-
ature in order to do no harm. In its introduction, the document claims that
PFA is an evidence-informed rather than evidence-based strategy, be-
cause much of the material is drawn from the crisis, trauma, and bereave-
ment literature and all recommendations have not yet been scientifically
validated in disaster (Brymer et al. 2006; Ruzek et al. 2007). The rapidity
of response, the inherent chaos and danger, and the limited resources have
so far made it challenging to conduct studies of the effectiveness of various
interventions during the immediate disaster response. Taking this into ac-
count, authors of the PFA Field Operations Guide considered the concerns
and warnings in the literature, and there is a growing consensus of support
for PFA among mental health experts.

Basics of Psychological First Aid


Detailed knowledge of the elements and goals of PFA will inform its accu-
rate implementation. The basic elements are described in Table 122.
Among the key resources in the PFA Field Operations Guide are a se-
ries of specific techniques and sample scripts meant to serve as examples for
responders working with survivors. Recommendations for learning PFA
include an initial didactic understanding through readings and classroom
or online material, as well as supervised practical exercises.

Special Populations
The PFA Field Operations Guide includes specific resources for working with
children, elderly individuals, bereaved persons, and other special populations.
Several adaptations and translations of the guide have evolved from the orig-
inal. In particular, adaptations of the PFA Field Operations Guide were cre-
ated for community-based religious professionals and school-based respond-
ers (adaptations and variations of the guide are available from the NCTSN
Web site [www.nctsn.org/trauma-types/natural-disasters/psychological-
first-aid]). It has since been translated into Spanish, Japanese, German, Swed-
ish, and Italian. After the May 2008 earthquake in China, the guide was trans-
lated into Mandarin and simplified Chinese.

Cultural Implications
The needs and responses of individuals from different cultures and back-
grounds play a part in early disaster response initiatives, including PFA.
More information is coming to light, but very little is known for certain
about how generic mental health assumptions and interventions should be
PSYCHOLOGICAL FIRST AID 207

TABLE 122. Elements and goals of Psychological First Aid


1. Contact and engagement: To respond to contacts initiated by survivors, or
to initiate contacts in a nonintrusive, compassionate, and helpful manner
2. Safety and comfort: To enhance immediate and ongoing safety, and to
provide physical and emotional comfort
3. Stabilization: To calm and orient emotionally overwhelmed or disoriented
survivors
4. Information gatheringcurrent needs and concerns: To identify
immediate needs and concerns, gather additional information, and tailor
Psychological First Aid interventions
5. Practical assistance: To offer practical help to survivors in addressing
immediate needs and concerns
6. Connection with social supports: To help establish brief or ongoing
contacts with primary support persons and other sources of support,
including family members, friends, and community helping resources
7. Information on coping: To provide information about stress reactions and
coping to reduce distress and promote adaptive functioning
8. Linkage with collaborative services: To link survivors with available
services needed at the time or in the future
Source. Adapted from Brymer et al. 2006.

defined or modified for a specific group of people. The World Health Or-
ganization (WHO) has issued a directive asking response organizations to
discourage mental health professionals from responding to disaster areas
where they are not familiar with the language or the culture (Inter-Agency
Standing Committee 2007). The PFA Field Operations Guide has been
translated into a number of languages, but the relevance and effectiveness
studies are yet to be completed. By NCTSN statistics, over 10,000 copies
of these translated guides were downloaded from the NCTSN Web site.
The simplified Chinese version was published in China, and more than
10,000 copies were distributed to the earthquake region (National Child
Traumatic Stress Network 2009). This distribution effort has not been
without controversy. International providers have implied that simply
translating and exporting the PFA Field Operations Guide may create a
Westernization of the crisis and grief response, and may not have rele-
vance in other cultures (Watters 2010). An emerging strategy for effective
intervention may be to pair up international responders with local mental
health professionals who know the culture and social system, or to pair
them with native social supports, such as religious, community service, or
educational professionals. Even so, there have been questions about the
relevance and usefulness of materials developed in the United States for
those in non-Western cultures. In an effort to address these concerns, the
208 DISASTER PSYCHIATRY: READINESS, EVALUATION, AND TREATMENT

PFA Field Operations Guide includes nonspecific culture alerts inter-


spersed throughout to alert providers to sensitive areas of understanding
and intervention as they relate to other cultures.
These culture alerts are useful for clues on how to initially approach and
interact with survivors, but they do not speak in depth to specific cultural
norms. As pointed out by the WHOs Inter-Agency Standing Committee
(2007) in its guidance for mental health professionals thinking of respond-
ing to other countries, there is no substitute for having a solid understand-
ing of the regional culture and language, prior disaster experience, and
knowledge of the legal environment at the disaster scene. One example is
the update issued by the American Psychological Association, based on the
Inter-Agency Standing Committee guideline mentioned above, for mental
health professionals considering participation in the 2010 Haiti earthquake
relief effort. The association recommended that unaffiliated volunteers be
discouraged from traveling to affected regions without meeting specific cul-
ture-based criteria or sponsorship by established relief organizations (Inter-
Agency Standing Committee 2010). Cultural issues surrounding disaster
response are discussed further in Chapter 6, Special Populations.

Children and Adolescents


The PFA Field Operations Guide integrates strategies throughout that are
designed to facilitate working with children and their parents (see Chapter
17, Child and Adolescent Psychiatry Interventions). It also offers child-
specific tip sheets for parents and other caregivers on how to work with
their own kids. Variations focus on how parents can help their own children
and how school personnel can use the techniques at times of disaster or
school crises.

Conclusion
Although this chapter is not intended to convey the totality of PFA, the
goals and basic elements are presented. Some components are knowledge
based and can be obtained through readings or a short online training
course. More significant is the need to develop the skills and attitudes that
translate these concepts and interventions into practice. This is best accom-
plished through live scenarios and through practical skill sessions mentored
by seasoned instructors. Many agencies and courses utilize the PFA con-
cepts, including the American Red Cross, the MRC, the American Psychi-
atric Association, and other disaster response organizations. Efforts are un-
der way to further evaluate PFA. Despite the difficulty of conducting disas-
ter outcomes research in a timely and ethical way, the widespread adoption
PSYCHOLOGICAL FIRST AID 209

of PFA is likely to lead to more specific data regarding its effectiveness as an


intervention tool and to further inform its use as an early intervention. As
physicians, psychiatrists must approach disaster settings aware of their own
skills as well as the full range of potential medical and psychiatric issues that
may move beyond the basic elements of PFA. Although PFA involves ini-
tially attending to basic needs, such as food, shelter, safety, and referral, the
use of PFA by psychiatrists in acute disaster settings may eventually lead to
more specific assessment, diagnosis, and therapeutic interventions as the di-
saster phases unfold and psychiatric illness emerges.

Teaching Points
Disaster mental health professionals should make an effort to do
the following:
Understand the origin and evolution of Psychological First Aid
(PFA) in disaster response.
Be aware of the strengths and limitations of PFA as an evidence-
informed approach.
Become familiar with the basic goals and principles of PFA.
Recognize that any mental health intervention, including PFA,
may have cultural implications.
Obtain information about the major PFA training resources.

Review Questions
12.1 Which of the following organizations in the United States has adopted
PFA as a major component of its disaster mental health curriculum?
A. National Child Traumatic Stress Network (NCTSN).
B. Civilian Volunteer Medical Reserve Corps (MRC).
C. American Red Cross.
D. All of the above.
E. None of the above.

12.2 In its Introduction, the PFA Field Operations Guide self-discloses as


utilizing which of the following strategies?
A. Evidence-based.
B. Evidence-informed.
C. Case-controlled
D. Expert-informed.
E. Expert-controlled.
210 DISASTER PSYCHIATRY: READINESS, EVALUATION, AND TREATMENT

12.3 Basic objectives of PFA include all of the following except


A. Establish a human connection in a nonintrusive and compas-
sionate manner.
B. Support positive coping skills and empower survivors to take an
active role in their recovery.
C. Enhance the immediate and ongoing safety of the individual by
providing physical and emotional support.
D. Offer practical assistance and connect survivors with relevant
support networks.
E. Facilitate emotional processing through psychological debrief-
ing of survivors using Critical Incident Stress Management tech-
niques.

12.4 True or False: The PFA Field Operations Guide integrates strategies
for working with children and their parents and also offers child-
specific tip sheets, for parents and other caregivers, on how to work
with children.

12.5 Which of the following statements regarding the cross-cultural rele-


vance of PFA is false?
A. The PFA Field Operations Guide has been translated into a
number of languages.
B. An emerging strategy for effective intervention may be to pair up
foreign mental health responders with either local mental health
professionals or other native service providers, such as religious,
community service, or educational professionals, who are al-
ready familiar with the culture and social norms.
C. PFA can be applied universally to all cultures, and the relevance
and usefulness of materials developed in the United States out-
side of Western culture has been well established.
D. Nonspecific culture alerts are interspersed throughout the PFA
Field Operations Guide to alert providers to sensitive areas of un-
derstanding and intervention as they relate to other cultures.
E. There is no substitute for having a solid understanding of the re-
gional culture and language, prior experience, and knowledge of
the legal environment at the disaster scene.
PSYCHOLOGICAL FIRST AID 211

References
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Additional Online Resources


Center for Disaster Medicine and Emergency Preparedness: Psychological First
Aid: Helping People Cope During Disasters and Public Health Emergencies
(program with a self-text). 2006. Rochester, NY, University of Rochester.
Available at: www.centerfordisastermedicine.org/disaster_mental_health.html
Disaster Psychiatry Outreach: The Essentials of Disaster Psychiatry: A Training
Course for Mental Health Professionals (Course Syllabus). New York, Disaster
Psychiatry Outreach, 2008. Available as DPOCourseSyllabus_052108.pdf at:
https://sites.google.com/a/disasterpsych.org/blog/File-Cabinet
National Child Traumatic Stress Network: Psychological First Aid for Youth Expe-
riencing Homelessness. 2009. Available at: www.hhyp.org/downloads/
HHYP_PFA_Youth.pdf
National Child Traumatic Stress Network: Psychological First Aid Online (includes
a 6-hour interactive course that puts the participant in the role of a provider in
a post-disaster scene). Available at: http://learn.nctsn.org
Nebraska Disaster Behavioral Health: Nebraska Psychological First Aid Curricu-
lum. Lincoln, University of Nebraska Public Policy Center, 2005. Available at:
http://www.disastermh.nebraska.edu/psychfirstaid.html
Ready.gov: Psychological First Aid for Students and Teachers. 2006. Available at:
http://www.ready.gov/kids/_downloads/PFA_SchoolCrisis.pdf
University of Rochester: Psychological First Aid for Employers and Supervisors.
Available at: http://www.omh.state.ny.us/omhweb/disaster_resources/pfa/
Employers.pdf