Imagine for a moment that you are a survivor of a powerful cyclone. Let’s say that you and all your loved ones managed to get out safely, but you arrived at the community shelter with only a backpack each of essential medicines, basic documents (such as your birth certificate and passport), and a few precious photos. There was not time to grab more. After the winds receded and you were allowed to go back home, you found that you could not. The cyclone rendered your beautiful home and all your possessions into a huge pile of rubble.

While you are grateful that you are not experiencing bereavement and that no one was badly injured, the plain truth is that you have nowhere to live and, as you find out in the ensuing days, nowhere to work. The building which housed your family business, along with thousands of dollars of stock, was also obliterated. Suddenly, you go from being an independent, prosperous, optimistic family to a dazed, exhausted, stressed group of survivors with a bleak sense of the future. You are dependent on civil authorities and disaster relief organisations for the most basic of supplies: water, a bit of food, and a few blankets, as you try to make yourselves comfortable on the school gymnasium floor. What are your needs? How do you feel? And what, in this situation, could happen for you to bring you and your family back to a “normal” (albeit new normal) existence as soon as possible?

In years past, with survival assured and your family together, your “needs” would have been defined mostly in terms of practical, material aspects: getting you immediate resources of food, shelter, and clothing, for example. Disaster experts and civil planners would have begun figuring out where you could be accommodated for the many months until your home, and probably many others in the community, could be re-built. They would also be generating a plan for that re-building. But tending to your emotional, psychosocial, and spiritual needs would have been strictly your domain.

With the advent of disaster mental health and the identification of PTSD (post-traumatic stress disorder), all that changed. Psychological First Aid was developed as a principal tool to use after an emergency, disaster, or other disruptive event. It now constitutes a crucial aspect of responding to and recovering from a destructive or disruptive event.

A definition and some characteristics

Psychological First Aid is an evidence-informed modular means of providing psychosocial support to individuals and families immediately after a disaster, terrorist or traumatic event, or other emergency. It consists of a set of helping actions which are systematically undertaken in order to reduce initial post-trauma distress and to support short- and long-term adaptive functioning and coping. Based on the principle of “do no harm”, it is provided increasingly by members of the general population, although mental health professionals are almost always involved as well (Ruzek et al, 2007; Brymer et al, 2006; The Australian Psychological Society and the Australian Red Cross, 2010).

It is common sense. Psychological First Aid includes basic common sense principles to promote normal recovery. These are actions to help people feel safe and calm, connected to others, hopeful, and empowered to help themselves, with access to physical resources, and emotional and social support. Psychological First Aid helps survivors to meet current needs; it promotes flexible coping and encourages adjustment. It is called “first aid” because it is the first thing that helpers might think to offer disaster-affected people, and it commonly occurs in the first days, weeks, and months after a disaster or other emergency (Australian Red Cross and Australian Psychological Society, 2010).

It meets basic standards. The principles and actions of Psychological First Aid meet four basic standards. They are:

• Consistent with research evidence on risk and resilience following trauma (that is, evidence-informed)
• Applicable and practical in field settings (as opposed to a medical/health professional office somewhere)
• Appropriate for developmental levels across the lifespan (there are different techniques available for supporting children, adolescents, and adults)
• Culturally informed and delivered in a flexible manner, as it is often offered by members of the same community as the supported individuals (Ruzek et al, 2007; Brymer et al, 2006).

It is community-based. Psychological First Aid is community-based (as opposed to occurring within the medical profession), and the programs are usually developed in consultation with the targeted community, with support being provided by members of that community. This tends to make it culturally responsive. It is low-cost, with the chief expenses being those of developing the training and public education materials. Being culturally sensitive and low-cost makes it sustainable. Because Psychological First Aid programs incorporate the traditional coping strategies of the community for which they are developed, they tend to build on the strengths of the culture.

The programs build the response capacity of people who, in a disaster, will be the family and friends of the survivors; appropriately, they will be the ones to whom survivors and those affected most often turn for psychological support. Psychological First Aid can be implemented by other than mental health professionals. The core skill is active listening, the skill at the heart of most therapeutic techniques, but also the first skill learned in any interpersonal or communication skills program. Participants in Psychological First Aid programs report that gaining listening skill improves not only their psychological supporting, but also their personal and professional relationships and communication (Jacobs, 2007).

It is designed for field delivery. Psychological First Aid can be found anywhere that survivors of trauma can be found: shelters, schools, staging areas, hospitals, and other community settings. It is designed for simple and practical administration in field settings (Ruzek et al, 2007), and even mental health practitioners involved in it acknowledge that offering support in the field is vastly different from doing it in their “regular” practice.

Why do we need Psychological First Aid?

Disasters, both natural and human-made, can strike at any time; sometimes we get a warning, and sometimes we do not. It is estimated that being involved in a significant traumatic event which causes Post-Traumatic Stress Disorder (PTSD) will mean a lifetime of that event continuing to be prevalent for 60.7% of men and 51.2% of women (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Lifetime prevalence for being exposed to a natural disaster is about 20% (Briere & Elliott, 2000; Kessler et al, 1995). In a study of 60,000 disaster survivors, between 18% and 21% indicated “severe” to “very severe” impairment. The rate of PTSD occurring in survivors of technological and human-made disasters ranges from 29% to 54%, while rates of PTSD for natural disasters are lower: between 4 and 8% (Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002). Some studies have found that impairment from being in a disaster can go on for years (Briere & Elliott, 2000; Crace, Creen, Lindy, & Leonard, 1993).

Clearly, disasters and emergencies are shocking events whose effects can stay with us for a long time, if not a lifetime. Ever since PTSD has been recognised as a disorder in the late 1970’s (Australian Red Cross, 2010), there has been increasing acknowledgement on the part of both the medical profession and those involved with disaster response that the psychological wellbeing of survivors and disaster-affected people needs to be tended to as well as the physical aspects. Mental health experts generally agree that early intervention can prevent more serious mental health problems later. The same mental health and disaster response experts also assert that most people are resilient enough, especially if they are given psychosocial support in the immediate aftermath of a disruptive event, that they will eventually go back to “normal” without additional, specialised mental health intervention, such as long-term counselling or psychiatric services (Norris, Friedman, Watson, Byrne, Diaz, & Kaniasty, 2002; Australian Red Cross, 2010).

Yet despite a widely recognised need to provide immediate help for trauma survivors, there is little research consensus about how best to assist individuals during those first hours and days after their experiences (Ruzek et al, 2007). The field of disaster relief has continued to be plagued by difficulties investigating the question of, “What intervention is best?” Emergency environments are chaotic by nature; thus, it is rarely possible to conduct the controlled research and evaluation that would clearly identify which interventions best offer psychosocial support after a disaster. Nevertheless, Psychological First Aid has wide popularity in increasing numbers of countries as the most efficacious method of assisting survivors in those first crucial hours and days after an event. Let us look at the events which have brought Psychological First Aid to this pre-eminent position.

The history and evolution of Psychological First Aid

As early as 1922, the War Office in the United States had recognised the need for support of its military personnel who were experiencing combat stress. Those setting up the programs for the soldiers acknowledged the need for the same five elements which have grown into today’s Psychological First Aid. That is, they appreciated that the soldiers needed to be made safe, calmed, empowered, connected to loved ones, and instilled with hope. Nevertheless, the main criterion for success of the interventions was not relief of stress symptoms. Rather, it was whether the soldier could be made functional again, and especially, whether he could return to active duty. The War Office program was called BICEPS, because it included the elements of “brevity, immediacy, centrality, expectancy, proximity, and simplicity” (Main, 1989).

The term Psychological First Aid was first coined by Drayer, Cameron, Woodward, and Glass (1954) in a manuscript they wrote for the American Psychiatric Association on request of the U.S. Federal Civil Defense Administration. The purpose of the manuscript was to provide guidance for managing in the aftermath of community disasters. By the 1970s the principles and foundations of crisis (psychological) intervention were being utilised in disaster work with adults (Raphael, 1977; Farberow, 1978) and in 1988, similar interventions were being implemented with children (Pynoos and Nader, 1988). By 1990 emergency organisations such as the Danish Red Cross were applying the principles as a preferred model for early intervention following exposure to a traumatic event. The principles have continued to gain widespread international acceptance, culminating in their inclusion in international guidelines (Knudsen, Hogsted, & Berliner, 1997).

Along with the development of the principles that we now know as Psychological First Aid, there has been a form of early mental health intervention called Critical Incident Stress Debriefing, which became popular in the mid-1980s. It is a psychological treatment intended to reduce the potential for psychological un-wellness that arises after exposure to trauma, and has generally consisted of “one off” sessions of a procedure in which survivors, disaster-affected others, and even first responders are able to “debrief” or talk about the trauma that they have just experienced. A structured group model designed to explore facts, thoughts, reactions, and coping strategies, its origins can be traced to efforts aimed at maintaining group morale and reducing psychiatric distress amongst soldiers immediately after combat (Mitchell, 1997).

Debriefing has been routinely offered in a number of settings on an international scale, including for victims of mass disasters, or individuals involved in traumatic incidents in the workplace, such as police officers. It is founded on the belief that promptly talking through traumatic experiences will aid people in recovering from potential psychological damage. It is usually offered on a voluntary basis, but there are groups for whom it is compulsory following trauma, including bank employees in both the UK and Australia and some UK police forces. The assumption is that debriefing can prevent the onset of PTSD, and some have suggested that it might also prevent employees who developed PTSD after a critically traumatic incident from suing their employers (The Professional Counsellor, 2011). A typical debriefing process takes place in a session two to three days after the trauma. Although initially designed to be used in groups, debriefing has also been used on individuals, couples and families (Carlier, Voerman & Gersons, 2000; Rose, Bisson, Churchill & Wessly, 2009).

Psychological First Aid vs Critical Incident Stress Debriefing

Because crisis intervention strategies have become one of the most widely used time-limited modalities of treatment, they have also – inevitably – come under scientific scrutiny for their effectiveness.

What the research says about Critical Incident Stress Debriefing

A number of reviews of the post-trauma intervention literature have concluded that there is no evidence that Critical Incident Stress Debriefing (CISD) prevents long-term negative outcomes (Litz et al., 2002; Bisson, 2003; McNally, Bryant, & Ehlers, 2003; Watson et al., 2003). For example, in a recent study of a group debriefing intervention with military personnel on active duty, researchers found that soldiers rated their satisfaction with CISD as high and mental health outcomes at follow-up did not worsen as a result of CISD. There were no differences, however, among the subjects who received CISD, those who received stress education, and those who only completed a survey. Researchers were measuring behavioural health outcomes (including PTSD), depression, general well-being, aggressive behavior, marital satisfaction, perceived organisational support, and morale. Heart rate and blood pressure readings before and after the sessions did not indicate a change in physiological stress, and subjective ratings of distress did not change pre to post-session (Litz et al, 2002). Two studies of CISD reported a higher incidence of negative outcomes in those who received CISD than in those who did not receive an intervention (Mayou, Ehlers, & Hobbs, 2000).

The Norwegian Knowledge Centre for the Health Services did an analysis of thousands of studies (a meta-analysis) in 2007, and – based on 34 studies that met its criteria for inclusion in the analysis – concluded that there was no effect of debriefing compared to no intervention during the first year after accidents and crises (Kornor, Winje, Ekeberg, Johansen, Weisaeth, & Ormstad, 2007).

There may be many possible explanations for why studies on CISD have resulted in negative or neutral findings, such as that the one-off intervention is too brief, or that it may increase anxiety. Nonetheless, many mental health experts are concerned that any intervention focusing on emotional processing right after a traumatic event may be harmful. Certainly, there has always been the controversy with debriefing: to whom should it be offered: survivors alone? Affected families? The responders who witnessed terrible sights in the course of rescuing people? And should people be made to talk about their experiences, or merely invited?

Accordingly, the general conclusion of those working in the field of mental health disaster response is that more research is needed before CISD should be routinely recommended in the immediate aftermath of a disaster (Watson, 2004). This seems especially sensible in view of how chaotic a post-trauma environment is, and how crucial it is to attend to pragmatic material needs, cultural and bereavement issues, and also the widely disparate needs of survivors as they go through recovery (Watson et al, 2002).

How Psychological First Aid is different from CISD

Psychological First Aid takes a very different tack from CISD, being very practically focused, and operating with the assumption that most people are resilient, and will recover well from a traumatic event if they are given basic support. In distinguishing Psychological First Aid from Critical Incident Stress Debriefing, it is important to note that Psychological First Aid is not about debriefing. It is not about minimally-trained field volunteers trying to obtain details of traumatic experiences and losses from survivors or responders, especially because such volunteers may not know how to respond to people making traumatic disclosures.

Because Psychological First Aid is often offered by community members whose main occupation is other than mental health, it is not about treating a “patient” or about labelling or diagnosing a person. It is not counselling, and as stated above, it is not something that only professionals, such as psychologists, counsellors, or psychiatrists, do. Similarly, it is not something that everyone affected by an emergency will need.

What Psychological First Aid promotes

Because disasters differ greatly from one another – as do the psychological reactions of the individuals, families, and communities who experience them – any model for intervention needs to be flexible, and adaptable to specific circumstances. The five principles which we know today as the framework for Psychological First Aid were first outlined by Hobfoll and his colleagues (2007), who declared that any psychosocial support in the hours and days following an emergency or mass catastrophe needed to promote:

1. safety
2. calmness
3. self-efficacy (self-empowerment)
4. connectedness
5. hope

These elements have provided a skeleton for developing the public health approach to disaster response that has been incorporated into a number of emerging Psychological First Aid programs (Benedek & Fullerton, 2007).

This article was adapted from the upcoming “Psychological First Aid” Mental Health Academy course. This short course will equip you to successfully enter a disaster relief setting or situation of narrower-scale adversity, and offer Psychological First Aid, promoting safety, calmness, empowerment, connectedness, and hope to survivors.

References

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