PSYCHOLOGICAL FIRST AID (PFA) / Shishir Subba
What is Psychological First Aid?
Psychological First Aid (PFA) is an approach to helping people affected by an emergency, disaster or traumatic event (APS, 2013). It describes a humane, supportive response to a fellow human being who is suffering and who may need support (Sphere, 2011; IASC, 2011). It is supported by disaster mental health expert immediately after of disaster. The intervention is designed to reduce initial distress caused by traumatic events by providing psychosocial care and support in which they focus on adjustment and coping. It helps to promote natural recovery among the survivors. This is done by helping people to feel safe, connect to the survivors with others (family members and close people), makes survivor calm and hopeful, links the survivor with social network, and helps in access to physical, emotional, and social support. One of the goals of PFA is to encourage and make the survivors feel able to help themselves. ‘Since 2002, psychological fist aid has been recommended as a key part of the provision of psychosocial support following disasters’ (APS, 2013).
PFA involves the following themes (WHO, 2011):
- Providing practical care and support,which does not intrude
- Assess needs and concerns of the survivors
- Helps people to address basic needs (e.g., food, water, information)
- Listens to people but does not pressure people to talk about traumatic events
- Comforts and help them to feel calm
- Helps in connecting people to information, services available, and social supports
- Protects people from further harm
Physical First Aid is used to reduce physical discomfort. Psychological First Aid is a strategy to reduce the painful range of emotions and responses experienced by the survivors. PFA is used with the concept that emotional distress is not always visible as a physical injury but is just as painful and debilitating. Reactions manifest differently at different periods of time during and after the incident. Reducing psychological reactions can lead to speedy recovery.
Disaster survivors experience a broad range of early reactions (e.g., physical, psychological, behavioral, spiritual) that can cause enough distress to interfere the recovery and coping process. PFA is provided to help in reducing disaster related reaction and increasing the process of recovery. It is provided not because survivors develop and suffers from severe mental health problems as a result of disaster. Some may take longer period to recover and cope but majority of them can recover quickly with care and support of disaster workers, family members, and friends. Thus, PFA is used immediately after the disaster, or days and weeks following the events. Some people may require further mental health support to assist recovery.
Aim of PFA
- To address emotional, practical needs and concerns
- To build people’s capacity (resilience) to recover
- To support recovery by helping people to identify their immediate needs, their strengths, and abilities to meet these needs (belief in one’s ability to cope predicts outcome)
- To be optimistic, positive, confidence in self can have positive outcome. PFA workers try to bring these positive aspects through different activities
- The primary aim of PFA is to protect and promote mental health and psychosocial wellbeing of survivors
PFA: What are the goals of PFA?
PFA primarily tries to reduce psychological distress by providing caring and comforting presence, providing support to empower the survivors by strengthening the existing coping skills, connecting support network including family members.
The goal is to create and sustain an environment of:
- Safety – to promote safety PFA workers reduce survivors from threat or harm, help to meet basic needs, medical attention, simple but accurate information, and provide physical and emotional comfort
- Calm & comfort – stabilize shocked, overwhelmed, disoriented people; create environment that is less stressful; listen to people’s story without forcing them to talk; tries to be compassionate, offer accurate information, inform about stress and coping, assures fearful and worried people about help
- Link survivor to his/her personal and social world – PFA workers help people to contact with friends and families, keep them together, help finding resources, respect culture, people, and family structure; offer practical help by directing or linking people to places where services are available.
- Self-empowerment – Helps to engage people to meet their own needs, assist in decision making, help to prioritize problems and solve by survivor themselves. Self efficacy builds confidence to fight with abnormal condition
- Promote hope – Be there with people, build hope that they (survivors) can recover, and reassure that their abnormal feelings are normal in abnormal condition
Who can and where PFA be delivered?
- It can be delivered by wide variety of people such as volunteers and trained responders in the community
- It is a humane, supportive, and practical response to people exposed to serious stress and may need support (most working in such situation are able to provide assistance, comfort, support)
- Workers can provide safety and support by respecting the capacity of the survivor
- PFA should be provided in safe places e.g., in community settings, near the disaster site (where distressed people are helped and supported such as shelter, camps, health centers, schools, etc.)
- Delivered through appropriate agencies (regional, district, local emergency management plan)
- It is a coordinated package and the response (by health professional, teachers, educational professionals, faith-based organization, red cross, psychosocial support) is key part of emergency response
How PFA works?
- PFA is an approach that is built on the concept of human resilience. It aims to reduce stress signs and assist in a healthy recovery
- PFA follows 3 L model – ‘Look’, ‘Listen’, and ‘Link’
- It begins with assessing the situation, population suffered, needs felt and expected
- First step of effective PFA is to bring calmness to the distressed. A calm mind is better placed to put his/her world back in order
- PFA helps to keep the communities calm in a crisis situation
- PFA workers communicate with survivors where needed. Expressing oneself is therapeutic. It reduces stress and feeling of upset. It also opens door for emotional support (if needed by survivor)
- Psychosocial support is provided to help survivors to make their own decision. Empowered feeling lead to self-decision, such regained confidence may lead to quick recovery
- Providing support is important to instill a sense of confidence and feeling that they can help themselves
- PFA helps survivors to prioritize what his/her next step that s/he need to do
- PFA helps to link survivors to existing support system, needed basic services, and bridge back to families that may help to regain or bounce back to normalcy. Linking to familial or community support is important
- PFA is more useful in rural areas. It is not necessary that a PFA should be a psychologist or mental health worker. PFA is not a replacement of counselor rather it works like an immediate help. Where there is no mental health practitioners, PFA is great source of help
- Studies have found that raised rates of PTSD is associated with peritraumatic dissociation and perceived poor social support. It is asserted that social care should be provided for those involved in disasters. Response should promote a sense of safety, self and community efficacy/empowerment, connectedness, calm and hope; access to social, physical and psychological support (cited by Bisson, J.I. & Lewis, C.,2009).
[3L Model (WHO,2011)
- Check for safety
- Check for people with obvious urgent basic needs
- Check for people with serious distress reactions
- Approach people who may need support
- Ask about people’s needs and concern
- Listen to people, and help them to feel calm
- Help people address basic needs and access services
- Help people cope with problems
- Give information
- Connect people with loved ones and social support]
PFA is delivered by mental health and other disaster response worker to the children, adolescents and families. PFA providers work along with varieties of response units such as first responder teams, emergency and primary health care, crisis response teams, organization, disaster relief organizations, etc. PFA workers work along with other experts in integrated approach. PFA is primarily focused on person and his/or psychological and social aspects but they also functions differently as required in the disaster condition and population affected.
PFA workers may involved in shelter, special need shelters, primary or emergency health care facilities, with relief workers, disaster assistance service centers, family reception and assistance centers, homes, and community settings. It is not about where or with whom a PFA works but more about what quality service s/he can provide to distressed people.
PFA workers function within a framework where they collect basic information of the situation. Then they do the rapid assessment of survivor’s basic needs and conditions and implements care and supportive activities in a flexible manner. Basically PFA workers help people to connect, make them safe and calm, provide safety and emotional and physical comfort, provide accurate information, and helps to address their immediate needs. They provide care and supports in culturally appropriate way to the survivors of various age, caste, and ethnic background. Such activities and help reduce the chances to develop more acute reaction and later PTSD.
What not to do?
- It is not useful (and sometimes may be harmful) to directly encourage disaster survivors to talk about what happened to them. It is like forcing to reexperience the traumatic event.
- Post-emergency settings are not clinical environment and it is inappropriate to conduct a clinical or psychological assessment
- As the name PFA itself indicates contact should be limited…provide simple support only like in physical first aid.
- Not to support or provide emotional support to people with marked sign of risk (e.g., suicidal tendency). It is important to refer such people to formal mental health services.
APS (2013) WHO (2011) state that PFA is:
- Not psychological debriefing (Psychological Defriefing is the formal version of providing emotional and psychological support immediately following a traumatic event with a goal of preventing the development of PTSD)
- Not obtaining details of traumatic experiences and losses
- Not treating
- Not labeling or diagnosing
- Not counseling
- Not something that only professionals can do
- Not something that everybody who has been affected by an emergency will need
How crisis events affect people?
- Distressing events include war, natural disasters, accident, fires, and violence which can affect person, family, and the entire community.
- Distressing events like earthquake expose people to uncertainty that can create stress and anxiety in different degrees
- Such event (e.g., earthquake) may result into loss of loved ones, separation, destruction of home, community, and death.
- People’s reactions to such events are manifold. Some people cannot tolerate, get confused, feel fearful or anxious, detached themselves from such event, or deny. Such reaction is quite normal in abnormal condition. In a situation where people collectively feel a sense of helplessness and hopelessness such reaction is understood as natural or normal. But some people can show severe reactions.The resulting reaction after of earthquake or in similar disasters depend on individual psychosocial functioning and the nature of disaster. Reactions to disaster depends on the following factors (WHO, 2011):
-Personally felt experience of nature and severity of event
-If they have similar type of previous experience
-The social support they get before and after the event
-Their physical condition
-Personal and family history of mental health problems
-Cultural backgrounds and traditions
-Age of the survivors, etc.
In such situation survivors (child, adolescents, adult) and even first responders may need psychological first aid
What are the core actions of PFA ?
- Contact and Engagement
- Safety and Comfort
- Information Gathering: Current Needs and Concerns
- Practical Assistance
- Connection with Social Supports
- Information on Coping
- Linkage with Collaborative Services
What and How to plan?
- Assess the disaster – nature of disaster, places/areas, people affected, duration and intensity, etc.
- Finding the available services and supports – People/authorities who are managing the crisis, team/people providing basic needs (Physical First Aid and location, shelter, food, water, material assistance, etc.)
- Find people’s access to different services
- Finding community member’s involvement
- Finding the existence of number of ‘active finding’ and ‘family reuniting service’
- Evaluate safety and Security concerns – Evaluating of events (aftershock), immediate environmental dangers
- Finding insecure and restricted areas for physical danger
- Finding out whether you are physically and mentally prepared as PFA worker
What the PFA worker should do during disaster?
- Get information, assess the situation, and the immediate needs of the survivors
- Locate oneself near the devastating areas so that help can be immediately provided
- Get connected with all the existing helping teams
- Establish human connection
- Use communication skills, relate with the situation and people
- Provide safety, information, physical and emotional comfort
- Calm and reorient emotionally overwhelmed survivors
- Find what their immediate needs and concerns are and gather additional information
- Connect the survivors with social network, family members and community helping resources, and all other social support and health networks (where necessary).
- Empower survivor, support adaptive coping effort, build strength, encourage to take active role in recovery
- Provide information that may help survivors to face effectively with the psychological impact of disaster
How to be professional in response?
- It is important to operate and provide services within the framework of an authorized disaster response system
- Response in a healthy, calm, courteous, organized, and helpful manner
- It is important to be visible and available to all
- Maintain confidentiality
- Remain within the scope of one’s expertise and designated role
- Referral system should be strictly maintained
- Be knowledgeable and sensitive to cultural diversity
- Be aware of and pay attention to one’s own emotional and physical reaction
How to deliver PFA?
- If in the site, observe but don’t intrude. Ask simple questions about how you can help. Be respectful, listen carefully
- Providing psychosocial support (food, water, blankets, tent, etc) is the best way to make contact or connect with the survivor. Team work is important
- Empathic understanding of the situation and people is must
- Be prepared when survivor avoids or get emotional while contacting
- Be sensitive, patient, calm, and responsive
- Speak slowly, use simple but concrete term. Avoid using acronyms and non-speaking words (avoid difficult technical terms while talking with with survivors (villagers)
- Be prepared to listen if survivor wants to talk. Talking is also therapeutic in nature. Use verbal and non-verbal communication skills
- Acknowledge the positive aspects and actions survivor has taken to keep him/herself safe
- Give information related to survivor’s immediate need, goal and link with relief party
- While giving information make it accurate and age-appropriate
- Remember – the goal of PFA is to reduce distress, find and help to get current needs, enhance coping strategies, promote adaptive functioning, etc.
How to work with survivors of different age group, caste or ethnic groups?
- While dealing with children, sit at child’s eye level. With school-age children use simple words. They can describe their feelings and concerns but listening carefully is important. Paying attention to children is important. For adolescents, talk “adult-to-adult” which convey the message that you respect his/her feelings, concerns, and questions
- Help parents/caregivers so that they can provide appropriate emotional support to their child
- Adults have both strength and weakness, vulnerable and invulnerable. Some can bounce back to normal quickly, others cannot. Avoid making prejudgment by appearance and confusion adult show. The reaction can be disaster-related disorientation. Physical exhaustion, social isolation, feeling of helpless or vulnerable may affect their vision, hearing capabilities, or self-confidence
- Physical or mental health disables, sick people need more assistance. Communicating directly with these people is important unless direct communication is difficult. Speaking simply and slowly is advisable. PFA worker can directly ask “What can I do to help?” to these people. All the time it is important to encourage them to be self-sufficient. Referral is advisable.
What to avoid while providing PFA?
- Avoid making assumptions about what survivors are experiencing
- Avoid assuming that every people who are exposed to disaster are traumatized
- Avoid pathologizing the conditions of survivors. Acute reactions are expected and understandable. Avoid labeling survivor’s reactions as “symptoms”. Avoid the terms ‘diagnosis’, ‘pathologies’, ‘disorders’ while speaking
- Avoid patronizing the survivors; avoid focusing on helplessness, weakness, mistakes, etc. Focus on what s/he has done positively or may have contributed helping others
- Avoid assuming that all survivors need to talk to PFA workers. For many, your physical presence, supportive and calm manner also instill a sense of safety and protected.
- Avoid offering inaccurate information. Always update the information.
NCTSN (2000). Psychological First Aid (Field Operation Guide) 2nd edition. National Child Traumatic Stress Network.
WHO (2011). Psychological First Aid: Guide for Field Workers
APS (2013). Psychological First Aid (2nd ed). Australian Psychological Society
Bisson, J.I. & Lewis, C. (2009) Systematic Review of Psychological First Aid,Commissioned by the World Health Organization.
MDH (213). Psychological First Aid. Office of Emergency Preparedness Education, Exercises, and Planning Unit, P.O. Box 64975 St. Paul, MN 55164-0975
IASC (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry 70 (4): 283-315.
The Sphere Project (2011). Humanitarian Charter and Minimum Standards in Disaster Response. Geneva: The Sphere Project. http:www.sphereproject.org