The following is a paper was originally written in Fall 2020 for COUC 997: Crisis and Trauma class at Liberty University.
Crisis Intervention: Psychological First Aid (PFA)
Sheri Collinsworth Cobarruvias
Department of Counselor Education and Family Studies, Liberty University
Author Note
Correspondence concerning this article should be addressed to Sheri Collinsworth Cobarruvias, Department of Counselor Education and Family Studies, Liberty University, 1971 University Blvd., Lynchburg, VA 24515, United States. Email: scobarruvias@liberty.edu
Abstract
Psychological First Aid (PFA) is a modularized treatment approach that can be utilized with anyone throughout the lifespan following the immediate aftermath of a disaster or non-disastrous traumatic situation. PFA is comprised of eight core actions that make up the primary objectives of this approach to crisis intervention. This intervention aims to provide practical, hands-on assistance to trauma survivors in a compassionate manner. Mental health and other disaster response personnel can utilize PFA with the proper training. This paper sought to identify PFA as a first-order intervention for treating trauma survivors. Items discussed include the methodology, development, and efficacy of PFA and how PFA can be explicitly applied to a population of frontline medical workers during the COVID-19 pandemic. Related information concerning training, limitations of intervention, and implications for use were discussed. Further investigation is needed to determine the efficacy of this treatment.
Keywords: psychological first aid, PFA, mental health, trauma survivors
Crisis Intervention Paper: Psychological First Aid (PFA)
Natural disasters, human-made disasters, and now a pandemic have dotted all of our reality in some form. Natural disasters such as hurricanes, tsunamis, fires, floods, earthquakes, and tornadoes are the norm. Some natural disasters (e.g., hurricanes, forest fires, tornadoes) can be predicted, and appropriate preparations can be made to reduce devastation, and still, that may not be enough. There are those natural disasters that cannot be predicted (e.g., earthquakes, tsunamis). Human-made disasters (e.g., some forest fires, 9/11 terrorist attacks, Boston Marathon Bombing, Paris Attacks, Orlando Nightclub Shooting, among many others) are entirely unpredictable. Lastly, the current global pandemic (COVID-19 or Coronavirus) has affected millions of lives. Each of these crises has left a wake of intense devastation in its path.
In the aftermath of these disasters, the survivors require their basic needs (i.e., food, clothing, shelter) be met before any counseling can occur (Brymer et al., 2006; James & Gilliland, 2017; Minihan et al., 2020; World Health Organization, War Trauma Foundation, and World Vision International, 2011). Psychological First Aid (PFA), a term first developed following an Australian railway disaster, provides immediate support for those who are suffering and in need of practical help resulting from traumatic events (Brymer et al., 2006; Minihan et al., 2020; Raphael, 1977, as cited in James & Gilliland, 2017; World Health Organization, War Trauma Foundation, and World Vision International, 2011). Globally, the COVID-19 pandemic has had a traumatic effect on frontline workers, business owners, employees, families, and so many more. This paper will discuss how PFA has been used to help those affected by this crisis. A description of the methodology, development, and efficacy of PFA will be presented. Application to frontline workers during the COVID-19 pandemic will be discussed to help the reader understand how PFA has been utilized. Finally, the paper will conclude with information on trainings and limitations of PFA.
Methodology of Intervention
When responding to a traumatic event, whether human-made or natural disaster, public health professionals must address the physical and emotional needs of those affected in the community (Parker et al., 2006). Of more significant concern is the growing psychological needs that overwhelm current mental health resources in the wake of large-scale crisis situations. Psychological First Aid (PFA) was created to address the fundamental psychological needs of survivors in a crisis while also attending to other basic needs (e.g., food, clothing, shelter, information gathering, ensuring safety; James & Gilliland, 2017; Minihan et al., 2020; Parker et al., 2006; Ruzek et al., 2007; World Health Organization, War Trauma Foundation, and World Vision International, 2011).
PFA is a short-term intervention used by public health personnel following a traumatic event to supplement frontline mental health providers (Parker et al., 2006). PFA does not necessarily need to be conducted by licensed mental health professionals, as not all disaster response workers are trained mental health professionals (Brymer et al., 2006; Minihan et al., 2020). Slaikeu (1990) suggested crisis intervention has two parts: PFA, which is referred to as a first-order intervention, and crisis therapy, which is referred to as a second-order intervention (as cited in James & Gilliland, 2017). Crisis therapy is described as an intervention that is delivered by trained, licensed mental health professionals. The following sections will give a brief overview of PFA as a first-order intervention and crisis therapy as a second-order intervention. Together, these two parts are what James and Gilliland (2017) designated as “crisis intervention.”
First-Order Intervention: Psychological First Aid
PFA is a manualized, evidence-informed, supportive response to help those in immediate need following a disaster, an act of terrorism, or trauma (Brymer et al., 2006; Minihan et al., 2020; Parker et al., 2006; Ruzek et al., 2007;World Health Organization, War Trauma Foundation, and World Vision International, 2011). PFA is comprised of eight core actions that are the central objectives of delivering immediate assistance in the aftermath of a traumatic event (Brymer et al., 2006; Ruzek et al., 2007). The purpose of PFA is to offer a practical, non-intrusive means of care and support (e.g., evaluating needs, addressing concerns, providing access to basic needs, listening, comforting, making connections with loved ones or needed services, protecting survivors from further trauma; Brymer et al., 2006; World Health Organization, War Trauma Foundation, and World Vision International, 2011). PFA is designed to be delivered by mental health professionals and other disaster and non-disaster response personnel found in a variety of different settings (e.g., first responder teams, incident command systems, primary and emergency healthcare, school crisis response teams, faith-based organizations, Community Emergency Response Teams (CERT), Medical Reserve Corp, Citizens Corp, hospital trauma centers, rape crisis centers, among other disaster relief organizations; Brymer et al., 2006; Ruzek et al., 2007).
It is essential to understand what PFA is not and what attitudes and behaviors to avoid when working with trauma survivors (Brymer et al., 2006; World Health Organization, War Trauma Foundation, and World Vision International, 2011). PFA is not meant to fix or cure anyone or take away the pain of the situation (James & Gilliland, 2017). PFA is not “psychological debriefing,” professional counseling or only conducted by licensed mental health professionals, nor is it analyzing the traumatic experience or uncovering survivors feelings about the event (Brymer et al. 2006; Minihan et al., 2020; World Health Organization, War Trauma Foundation, and World Vision International, 2011). PFA providers should avoid making assumptions about the survivor’s experiences or that everyone will be traumatized by the event (Brymer et al., 2006). Commonly used clinical terms such as pathology, symptoms, diagnoses, conditions, and disorders, should be avoided as most acute stress reactions are common. Focus on the survivor’s strengths and what they are doing that has been effective. It is essential to understand that not everyone wants or needs to talk. The PFA worker’s physical presence may be more beneficial at that moment than anything that could be said (Brymer et al., 2006). Lastly, do not offer information for the sake of providing information. If there is no information to give, it is best to simply state there is no new information available at this time.
Second-Order Intervention: Crisis Therapy
Crisis therapy is required when survivors’ psychological needs are not met through PFA (World Health Organization, War Trauma Foundation, and World Vision International, 2011). Most intense stress responses are expected. However, there may be those survivors who cannot control or lack the ability to control their emotions and can become a threat of harm to self or others, or they are unable to care for themselves or their children. Crisis therapy is an intervention provided by trained, licensed clinical mental health professionals (e.g., Licensed Professional Counselors, Licensed Clinical Social Workers, Licensed Marriage and Family Therapists). For the sake of space and brevity, the focus of this paper is on PFA.
Development of Intervention
The U.S. Department of Veterans Affairs, in conjunction with the National Child Traumatic Stress Network (NCTSN) and the National Center for PTSD, developed a guided approach to PFA for assisting people following a disaster or act of terrorism (Brymer et al., 2006; James & Gilliland, 2017). The purpose of this intervention is to decrease initial suffering, nurture adaptive functioning, and promote resilience (James & Gilliland, 2017; McCart et al., 2020; Owen & Schimmels, 2020; Ruzek et al., 2007; Sulaiman et al., 2020). In the following sections, the eight core actions of PFA will be introduced and briefly discussed, along with the goals for each action.
Core Actions of PFA
PFA was developed around eight core actions that provide a practical means of initial support, connection to resources, safety, and stability to encourage resiliency (McCart et al., 2020; Owen & Schimmels, 2020; Ruzek et al., 2007). James and Gilliland (2017) cautioned PFA was not created as a means to cure or fix anyone suffering a trauma, but instead as a means to provide physical and emotional support in the wake of a trauma. The level of assistance and time dedicated to each person is dependent on the immediate needs of the survivors (Brymer et al., 2006; James & Gilliland, 2017; Ruzek et al., 2007). It is important to note that some people may not need or want the assistance available, nor should it be forced (James & Gilliland, 2017; Ruzek et al., 2007; Sulaiman et al., 2020). Additionally, care and caution should be taken concerning the presentation of when or if certain information should be provided (Ruzek et al., 2007). Each of the eight core actions (contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connections, coping, linkage to collaborative services) will be briefly discussed and goals identified in the following section.
Contact and Engagement.
In the aftermath of a traumatic event, the goal of this core action is for PFA providers to dispatch and quickly establish contact with the affected person(s) or community (Brymer et al., 2006; James & Gilliland, 2017; Ruzek et al., 2007). The challenge for PFA providers is building positive relationships when there is little opportunity to “get to know” people in the same manner as in clinical practice. Caution and care are essential when initiating contact with survivors—respect, patience, and understanding are needed. Help is not always welcomed, and there is a better chance of acceptance when the provider identifies and addresses the survivor’s immediate concerns (Brymer et al., 2006; James & Gilliland, 2017; Ruzek et al., 2007).
Safety and Comfort.
Before PFA providers can accomplish the goal of these core actions, physical or emotional comfort, workers must confirm survivors are physically and psychologically safe (Brymer et al., 2006; James & Gilliland, 2017; Ruzek et al., 2007; Sulaiman et al., 2020). Certain situations may influence dysfunctional, maladaptive, and aggressive behaviors (e.g., expressions of intense anger or rage, making threats to harm self or others), thus leaving all those involved at risk of being harmed. At those times, professional medical personnel or law enforcement should be notified. Being alert to medical issues (e.g., pre-existing conditions) of the survivor, further exposure to trauma, re-traumatization due to inaccurate information, violations of privacy (e.g., reporters, onlookers, attorneys) is vital to keeping survivors safe (Ruzek et al., 2007). Providing accurate information concerning next steps, what is being done by support systems in the community, what information is currently available about the event, availability of support services, and self and family care all go into providing safety and comfort to those affected by traumatic circumstances (Brymer et al., 2006; James & Gilliland, 2017; Ruzek et al., 2007; Sulaiman et al., 2020).
Stabilization.
It is not always necessary to try to calm a person’s emotions following a trauma. The intense emotions one is experiencing are a normal and expected part of the trauma experience—support is needed, of course (Ruzek et al., 2007). However, the goal of this core action is necessary for those who struggle with understanding the gravity of the situation or have trouble responding to support (e.g., those unable to answer questions, uncontrollable crying, hyperventilating, severe involuntary reactions; Brymer et al., 2006; James & Gilliland, 2017; Ruzek et al., 2007). Enlisting the help of family members or friends (if available) may also be necessary (Ruzek et al., 2007). There are several options the provider can take in stabilizing distraught individuals. For example, giving them space to be alone, being present, utilizing “grounding” techniques that will help survivors remain in the present, and guiding them through troublesome thoughts and emotions (Ruzek et al., 2007).
Information Gathering: Current Needs and Concerns.
In the aftermath of a traumatic event, survivors are in immediate need of their essential needs (i.e., food, clothing, shelter), along with obtaining relevant information concerning the safety of involved family members, the status of the current situation, and medical attention (e.g., to address a physical illness or need for medications; Owen & Schimmels, 2020; Ruzek et al., 2007). The immediate goal of this core action is for the PFA provider to acquire needed information from survivors to provide additional services (e.g., medical, psychological, housing, food pantries, clothing, social support, substance abuse treatment; Brymer et al., 2006; James & Gilliland, 2017; Ruzek et al., 2007). Care and sensitivity are needed on the part of the provider in gathering information so as not to offend or push away trauma survivors (Ruzek et al., 2007).
Practical Assistance.
Subsequent stressors, problems, and adversities following a traumatic event adds substantial strain on the survivor (Ruzek et al., 2007). As a result, survivors may not take care of themselves as needed. A fundamental aspect of PFA is helping with current or possible issues that might arise. The goal of this core action is to identify the present need, ascertain the specific problem, and determine how the provider can deliver practical assistance to meet the need or concern (e.g., setting appointments, making phone calls, completing paperwork; Brymer et al., 2006; James & Gilliland, 2017; McCart et al., 2020; Owen & Schimmels, 2020; Ruzek et al., 2007).
Connections with Social Supports.
Making contact with family members and friends in the aftermath of a disaster is very important. The goal of this core action is for PFA providers to assist survivors in making contact with friends and loved ones (i.e., in person, by phone, email, text; Brymer et al., 2006; James & Gilliland, 2017; McCart et al., 2020; Owen & Schimmels, 2020; Ruzek et al., 2007). Psychoeducation on the importance of social support and the need to support others may be necessary for survivors (Ruzek et al., 2007).
Information on Coping.
The immediate purpose of PFA is to assist survivors in obtaining their basic needs, provide physical and emotional stability, and offer practical assistance. Nevertheless, the goal of this core action is for PFA providers also to provide psychoeducation concerning the trauma (e.g., facts about the event, assistance to survivors, service distribution), expected emotional reactions (i.e., “common” responses of others in similar situations), and effective means of coping (e.g., self-care, family care) to enable appropriate functioning (Brymer et al., 2006; James & Gilliland, 2017; McCart et al., 2020; Owen & Schimmels, 2020; Ruzek et al., 2007; Sulaiman et al., 2020). Psychoeducation concerning stress reactions should include information concerning positive (e.g., social support, proper rest, positive distracting activities) and negative (e.g., isolation, refusing assistance, not discussing feelings, substance abuse, increased work hours) coping strategies, relaxation skills, anger management, sleep hygiene, and combating negative beliefs about the trauma (McCart et al., 2020; Ruzek et al., 2007; Sulaiman et al., 2020).
Linkage to Collaborative Services.
The PFA contact cannot help survivors meet all of their needs; however, the goal of this core action is for PFA providers to assist with making connections with collaborative services (Brymer et al., 2006; James & Gilliland, 2017; Ruzek et al., 2007). Assistance may entail giving a detailed explanation on how this agency is helping survivors in this situation, introducing the survivor to the agency representative (e.g., mental health, family services, relief workers), obtaining phone numbers of various agencies that can provide needed services, making phone calls, providing written contact information for the referral, and offering relevant handouts about the services provided by the agency (McCart et al., 2020; Ruzek et al., 2007; Sulaiman et al., 2020). Additionally, to maintain a sense of continuity of care, the PFA provider should offer their contact information to those they are working with to re-connect if needed (McCart et al., 2020; Ruzek et al., 2007).
Efficacy
Despite the widespread use of PFA, empirical evidence demonstrating PFA’s efficacy is scarce (Ng, 2020; Shultz & Forbes, 2013). According to Brymer et al. (2006), PFA is considered an “evidence-informed” approach, meaning certain features of PFA are supported by research. Regardless of the lack of research concerning PFA, disaster mental health experts describe PFA as the “acute intervention of choice” (Brymer et al., 2006, p. 5). PFA is the recommended and often utilized treatment intervention, over psychological debriefing, by the American Red Cross, National Child Traumatic Stress Network, National Center for PTSD, and the World Health Organization (American Red Cross, 2020; Brymer et al., 2006; James & Gilliland, 2017; Minihan et al., 2020; Ruzek et al., 2007; World Health Organization, War Trauma Foundation, and World Vision International, 2011). Psychological debriefing is unsuccessful in helping survivors following a trauma, as many survivors do not want or feel the need to talk about their experience (James & Gilliland, 2017; Shultz & Forbes, 2013; World Health Organization, War Trauma Foundation, and World Vision International, 2011). From the existing literature on PFA, studies have shown PFA is a simple, cost-effective treatment that can decrease stress, increase hope, improve the outlook of social support, empower those with suicidal ideation to seek assistance (Minihan et al., 2020; Ng, 2020; Saltzman et al., 2020; Shultz & Forbes, 2013). Further research is necessary to determine empirical support for this approach (Brymer et al., 2006; Shultz & Forbes, 2013)
Target Population
The COVID-19 Pandemic has affected billions of people, globally, and in so many ways (e.g., illness [either self or others], death, work conditions [frontline or essential workers], job loss, financial hardships, psychological issues; social isolation or distancing, working from home or distance education; Blake et al., 2020; Centers for Disease Control and Prevention, 2020; Minihan et al., 2020; Ng, 2020; Nurmagambetova & Assimov, 2020; Omari et al., 2020; Saltzman et al., 2020; Sulaiman et al., 2020; World Health Organization, 2020; Yue et al., 2020). From the onset of this pandemic, frontline workers (e.g., medical personnel) have been hit hard, physically and mentally, with the demands of long work hours, the threat of infection, and concern for their families (Blake et al., 2020; Sulaiman et al., 2020). PFA applies to many different populations and cultures (Brymer et al., 2006; World Health Organization, War Trauma Foundation, and World Vision International, 2011). The following section will discuss how PFA can be applied to frontline workers during this pandemic.
Frontline Workers, Mental Health, and the COVID-19 Pandemic
Frontline workers (i.e., medical personnel) in hospitals around the world are working long hours, under stressful conditions, with very little sleep or nourishment to treat those who are suffering from Coronavirus (the virus that caused COVID-19; Blake et al., 2020; Centers for Disease Control and Prevention, 2020; Sulaiman et al., 2020; World Health Organization, 2020). In addition to the daily physical stress, medical professionals are also experiencing the detrimental psychological effects of COVID-19 (Blake et al., 2020; Owen & Schimmels, 2020; Sulaiman et al., 2020). Through the use of PFA, studies have shown how this intervention promotes a sense of calm, safety, hope, decreased stigmatization, normalization of stress responses, increased self-care, and empowerment to seek out further assistance for frontline workers (Blake et al., 2020; Ng, 2020; Owen & Schimmels, 2020; Sulaiman et al., 2020).
Related Information
Much is written concerning PFA and how it is utilized in disaster or non-disaster situations. Shultz and Forbes (2013) documented the increase of PFA courses in the post-9/11 era. In the following sections, training, limitations of PFA, and implications and conclusions will be discussed. Further research is necessary concerning the efficacy of PFA with trauma survivors.
Training
Since the tragic events of 9/11 in New York City, Pennsylvania, and Washington, D.C., numerous courses have been developed to train first-responders and disaster mental health providers (Shultz & Forbes, 2013). The beauty of PFA is that any first-line disaster provider can learn the tools necessary to be of benefit to trauma survivors (Brymer et al., 2006; Shultz & Forbes, 2013; World Health Organization, War Trauma Foundation, and World Vision International, 2011). From their research, Shultz and Forbes (2013) identified several PFA training programs for a variety of target populations such as disaster survivors, parents of young children, children, public health workforce, disaster responders, public health and healthcare professionals, nursing home residents, and personnel, humanitarian crisis survivors, and refugees. It is important to note that each one of these populations has unique needs and requires PFA. PFA courses are offered through the National Child Traumatic Stress Network, National Center for PTSD, Substance Abuse and Mental Health Services Administration, The Advertising Council, U.S. Department of Homeland Security, The National Center for School Crisis and Bereavement, Johns Hopkins Center for Public Health Preparedness, Center for the Study of Traumatic Stress, Uniformed Services University of the Health Sciences, Medical Reserve Corps., and American Red Cross, among many other state and local agencies (Shultz & Forbes, 2013).
Limitations
As with any form of treatment, there are limitations that practitioners must consider. Limitations of this approach to crisis intervention include the method of service delivery, possible breaches of confidentiality, lack of empirical-evidence of efficacy (Minihan et al., 2020; Shultz & Forbes, 2013). As noted previously, PFA providers do not need to be licensed professionals; however, it is incumbent of the provider to seek professional help for the survivor if the provider is not qualified to help (Minihan et al., 2020). Additionally, due to the nature of the meeting between providers and survivors, confidentiality may be at risk (Brymer et al., 2006). Every effort should be made to protect the confidentiality of the survivor.
Implications and Conclusions
PFA is an intervention developed to meet the immediate physical and psychological needs of anyone, throughout the lifespan, following a disaster or traumatic situation (Brymer et al., 2006; Minihan et al., 2020; Parker et al., 2006; Ruzek et al., 2007; World Health Organization, War Trauma Foundation, and World Vision International, 2011). Eight core actions make up PFA’s central objectives (contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connections, coping, linkage to collaborative services; Brymer et al., 2006; James & Gilliland, 2017; Ruzek et al., 2007). The purpose of PFA is to offer practical assistance to trauma survivors in a supportive, non-intrusive manner (Brymer et al., 2006; World Health Organization, War Trauma Foundation, and World Vision International, 2011). PFA was created to be utilized by mental health professionals and other disaster and non-disaster response personnel; therefore, professional licensing is unnecessary (Brymer et al., 2006; Ruzek et al., 2007). In this paper, PFA was discussed as a first-order intervention for treating trauma survivors. Methodology, development, and efficacy of PFA were discussed and applied to frontline workers’ population amid the COVID-19 pandemic. Lastly, related information included trainings, limitations, and implications for the use of PFA.
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