DATE: September 25, 2009

TO: MRC DISASTER BEHAVIORAL HEALTH WORKGROUP

FROM: JIM SHULTZ

PSYCHOLOGICAL FIRST AID MODELS AND DEFINITIONS

1954. United States. The expression, “psychological first aid” is introduced in an article
entitled, “Psychological First Aid in Community Disasters,” prepared by the
American Psychiatric Association Committee on Civil Defense. The JAMA article is
attached for your review.

1990s. United States. Work of Gerald Jacobs, University of South Dakota.

Community-based Psychosocial Support model developed by Jacobs for
International Federation of Red Cross/Red Crescent Societies. Nebraska PFA is based
on IFRC model. Seven key elements (see attached article by Jacobs):

1. Crisis events and psychosocial support

2. Stress and coping
3. Loss and grief
4. Community-based psychosocial support
5. Psychological first aid and supportive communication
Active listening
Stay close
Accept feelings
Provide general care and practical help
6. Children
7. Supporting volunteers and staff

2000. New South Wale, Australia. Centre for Mental Health Services and NSW
Institute of Psychiatry (2000). Disaster Mental Health Response Handbook. North
Syndney, New South Wales, Australia: NSW Health Department.

Psychological first aid involves approaching and offering support, reassuring and
ensuring safety, comforting and communicating. If the person wishes to talk
about their experience this can be supported but it is inappropriate to probe for
psychological reactions at this early stage. Information necessary for appropriate
actions should be sought and provided. Links with families and significant others
should be ensured whenever possible and support provided while there is
separation (Raphael, 1993).

Components of psychological first aid include the following:

• The basic human responses of comforting and consoling a distressed person.
• Protecting the person from further threat or distress as far as is possible.
• Furnishing immediate care for physical necessities, including shelter.
• Providing goal orientation and support for specific reality-based tasks.
• Facilitating reunion with loved ones from whom the individual has been separated.
• Sharing the experience.
• Linking the person to systems of support and sources of help that will be ongoing.
• Facilitating the beginning of some sense of mastery.
• Identifying needs for further counselling or intervention.

The ABC of psychological first aid

These issues can be summarised by the ABC of psychological first aid:

• Arousal. This involves reducing very high arousal, comforting and consoling
distressed survivors, facilitating reunion with loved ones, protecting from further threat,
and ensuring physical necessities.

• Behaviour. The person showing behavioural disturbances should be protected from

harm resulting from these, and linked to systems of support. Facilitating some sense of
mastery will be important.

• Cognition. Cognitive disturbances such as dissociation should be dealt with through

general support, information provision and good orientation to specific reality-based
tasks, sharing the reality of the experience if the person wishes to talk. Mental state
assessment should include potential organic factors such as head injury or toxic effects,
and linking the person to ongoing systems of social support.

2002. United States. National Institute of Mental Health (2002). Mental Health and
Mass Violence: Evidence-based Early Psychological Intervention for
Victims/Survivors of Mass Violence. NIH Publication No. 02-5138. Washington DC:
U.S. Government Printing Office.

Psychological first aid: Pragmatically oriented interventions with survivors or

emergency responders targeting acute stress reactions and immediate needs.
The goals of psychological first aid include the establishment of safety (objective
and subjective), stress-related symptom reduction, restoration of rest and sleep,
linkages to critical resources, and connection to social support.

2003. United States. Butler AS, Panzer AM, Goldfrank LR--(2003). Preparing for the
Psychological Consequences of Terrorism: A Public Health Strategy. National
Academy of Science, Board of Neuroscience and Behavioral Health. Washington DC:
National Academies Press.
Psychological first aid refers to a set of skills identified to limit the distress and
negative behaviors that can cause fear and arousal.
2004. United States. U.S. Department of Health and Human Services (2004). Mental
Health Response to Mass Violence and Terrorism: A Training Manual. DHHS Pub.
No. SMA 3959. Rockville MD: Center for Mental Health Services, SAMHSA.

(Under heading of Psychological First Aid pp35-36):

Emergency intervention involves three basic concepts: protect, direct, and
connect (Myers and Wee, 2003)…

Psychological support involves:

• Comforting the distressed survivor
• Addressing immediate physical necessities
• Supporting reality-based practical tasks
• Providing concrete information about what will happen next to increase a
sense of control
• Listening to and validating feelings
• Linking the survivors to systems of support
• Normalizing stress reactions to trauma and sudden loss
• Reinforcing positive coping strengths
(Citations: Centre for Mental Health Services and New South Wales, Australia
Psychiatric Institute, 2000; Osterman and Chemtob, 1999; Young, 1998; Raphael et al.,
1996; Myers, Zunin and Zunin, 1990)

2006. United States. Young BH (2006). Adult Psychological First Aid. In Ritchie EC,
Watson PJ, Friedman MJ (eds.) Interventions Following Mass Violence and
Disasters. New York, NY: Guilford Press.

Psychological First Aid (PFA) is defined here as the use of pragmatic-oriented

interventions delivered during the immediate-impact phase (first 4 weeks) to
individuals who are experiencing acute stress reactions or who appear at risk for
being unable to regain sufficient functional equilibrium by themselves, with the
intent of aiding adaptive coping and problem-solving.

2005. United States. Everly GS, Flynn BW: Principles and Practice of Psychological
First Aid;and Everly GS, Parker CL. Psychological First Aid for Disaster Workers
(workshop). Baltimore MD: Johns Hopkins University.

Psychological first aid is a supportive and compassionate presence designed to

reduce acute psychological distress and/or facilitate continued support, if
necessary.

PFA “CORE ELEMENTS” (Everly, Parker):

• Basic communication techniques. Reflective listening.
• Recognition of basic human needs.
• Recognizing benign from malignant psychological/behavioral reactions
 • Educating about reactions
• Basic stress management for disaster survivors
• Referral for further mental health support, as indicated

2005. United States. NCCTS/NCPTSD. Psychological First Aid Field Operations

Guide

Psychological First Aid (PFA) is an evidence-informed, modular approach to

assist children, adolescents, adults, and families in the immediate aftermath of a
disaster.

PFA “CORE ACTIONS”

• Contact and engagement

• Safety and comfort
• Stabilization
• Information gathering
• Practical assistance
• Connection to social supports
• Information on coping
• Linkage with collaborative services

2007. New Zealand. “Psychological First Aid.” Dr. Daniel de Klerk. Air New Zealand
Medical Unit. Auckland International Airport, October, 2007. Cites the 2003 NAS
definition and continues, Psychological first aid is as natural, necessary, and
accessible as medical first aid. Psychological first aid means nothing more
complicated than assisting people with emotional distress resulting from an
accident, injury, or sudden shocking event.

2008. United States. Schreiber M, Gurwich R, Wong M. LISTEN PROTECT

CONNECT model of psychological first aid for use in schools. See attachment.

1. Listen
2. Protect
3. Connect
4. Model calm and optimistic behavior
5. Teach

2009. Australia. Australian Psychological Society (2009). Guidelines for the

provision of psychological support to people affected by the 2009 Victorian
bushfires. (See attachment)
PFA “CORE COMPONENTS”

Promote safety
• Help people meet basic needs for food and shelter, and obtain emergency
medical attention
• Provide repeated, simple and accurate information on how to get these basic
needs
Promote calming
• Listen to people who wish to share their stories and remember that there is no
right or wrong way to feel
• Offer accurate information about the disaster and the relief efforts underway to
aid understanding
Promote self and community efficacy
• Engage people in meeting their own needs and foster adaptive coping
Promoted connectedness
• Help people contact friends and loved ones
• Keep families together
• Keep children with parents or other close relatives whenever possible
Promote hope
• Find ways to enhance people’s natural resilience

SUMMARY DRAWING UPON MULTIPLE MODELS:

Brief description of psychological first aid by Betty Pfefferbaum, 2007:

PSYCHOLOGICAL FIRST AID

Betty Pfefferbaum, MD, JD

Paul and Ruth Jonas Chair

Professor and Chairman
Department of Psychiatry and Behavioral Sciences
College of Medicine
University of Oklahoma Health Sciences Center
Director,Terrorism and Disaster Center
National Child Traumatic Stress Network
February 2007

Put simply, psychological first aid is “the first aid received by a person in trouble” (American
Psychiatric Association Committee on Civil Defense 1954, p. 36). It requires support and
compassion to assist those experiencing acute psychological distress in the wake of a disaster
and is designed to promote adaptive coping and natural recovery and to facilitate access to
other forms of assistance as needed (Everly & Flynn 2006; Parker, Everly, Barnett & Links
2006). Psychological first aid recognizes a hierarchy of needs which places survival, safety, and
security as foremost concerns (National Institute of Mental Health [NIMH] 2002). Most disaster
survivors do not need formal mental health treatment but benefit from support and information.
The goals of psychological first aid include protecting survivors from additional harm, reducing
physiological arousal, mobilizing support for those who are most distressed, keeping families
together and facilitating the reunion of loved ones, providing information and fostering
communication, and using effective risk communication strategies (NIMH 2002). All
interventions, including psychological first aid should be developmentally appropriate and
culturally sensitive.

The National Child Traumatic Stress Network (NCTSN) and National Center for PTSD
(NCPTSD) recently developed an evidence-informed modular approach to psychological first
aid for use by mental health professionals and other disaster response workers to provide early
assistance to affected individuals as part of an organized disaster response effort (NCTSN &
NCPTSD 2006). Their psychological first aid manual focuses on, and provides guidance in,
establishing a connection in a non-intrusive compassionate manner, enhancing safety and
providing physical and emotional comfort, calming and orienting overwhelmed and distraught
survivors, helping survivors articulate their needs and concerns and gather information, offering
practical assistance and information to address immediate needs and concerns, connecting
survivors to social support networks, supporting adaptive coping and encouraging active
participation in recovery, providing information to help survivors cope, and facilitating continuity
by clarifying the responder’s role and by linking survivors to other individuals or services
(NCTSN & NCPTSD 2006). Formal evaluation is only now being addressed with numerous
complications expected in field testing. The International Federation of Red Cross and Red
Crescent Societies (n.d.) also recently published a psychological first aid manual which includes
many of the same principles and which contains modules on psychological support, stress, and
coping; communication; community self-help; populations with special needs; and needs of
responders.

REFERENCES

American Psychiatric Association Committee on Civil Defense (1954) Psychological first aid in community
disasters. Journal of the American Medical Association 156(1): 36-41.

Everly GS, Jr. & Flynn BW (2006) Principles and practical procedures for acute psychological first aid
training for personnel without mental health experience. International Journal of Emergency Mental Health
8(2): 93-100.

International Federation of Red Cross and Red Crescent Societies (n.d.) Community-based psychological
support training manual Retrieved November 13, 2006, from
http://www.ifrc.org/what/health/psycholog/manual.asp.

National Child Traumatic Stress Network and National Center for PTSD. (2006) Psychological first aid:
Field operations guide (2nd ed.) Retrieved November 13, 2006, from
http://www.ncptsd.va.gov/ncmain/ncdocs/manuals/PFA_V2.pdf.

National Institute of Mental Health (2002) Mental health and mass violence: Evidence-based early
psychological intervention for victims/survivors of mass violence. A workshop to reach consensus on best
practices NIH Publication No. 02-5138, Washington, DC: U.S. Government printing office.

Parker CL, Everly GS, Jr., Barnett DJ & Links JM (2006) Establishing evidence-informed core intervention
competencies in psychological first aid for public health personnel. International Journal of Emergency
Mental Health 8(2): 83-92.