Presented by: Dr Tina Sideris
“Painful emotional experiences become enduringly traumatic when there is an absence of relationships, or connection with others, in which they can be held.”
Psychological First Aid (PFA) has been identified as the preferred first line psychosocial intervention in disaster, mass violence, and emergency situations. By 2009, the World Health Organization concluded that psychological first aid, rather than psychological debriefing, should be offered to people in severe distress after being recently exposed to a traumatic event.
What is it not?
- Not a formal psychological intervention
- Not a psychological debriefing
This conclusion came on the back of research on the psychological debriefing model, which identified a number of concerns with that approach.
- Key concerns with the psychological debriefing model:
- Not effective in preventing post-traumatic stress disorder
- Can exacerbate stress
- Not culturally sensitive
- Not easily accessible at the point of need – requires professional experts
- It’s potentially harmful
- Tends to medicalise and pathologise
The general consensus amongst trauma experts is: don’t rush in to provide psychotherapy or formal psychological intervention too soon. In this regard, Psychological First Aid is the more appropriate tool.
A range of PFA models which share a set of underlying principles, have been developed and applied. These are based on the extrapolations of a worldwide panel of trauma experts, psychologists and psychiatrists working in the field of disasters and the treatment of those exposed. Recognising the diversity of disaster and emergency events, and locally specific contexts, rather than specifying a particular model of intervention, these experts came to a general agreement on principles to inform interventions. Noting the various ways in which extreme events may reach traumatic proportions, they stated at the outset that people’s reactions should not be perceived as pathological or necessarily as indicators of future clinical disorders.
Drawing on existing research, five empirically supported principles were identified to inform intervention at early and mid-term stages.
These were identified as promoting:
Promoting a Sense of Safety (physical safety, emotional safety, welfare of relatives)
Promoting a sense of safety addresses the psycho-physiological stress response designed for short immediate response to, and protection from, threat. Prolonged activation of the stress response leads to physical and mental illness.
Actively Encouraging Calming (grounding, breathing, prioritising needs, problem focused coping)
Actively encouraging calming is directed at avoiding sustained levels of emotionality and hyper arousal.
Initially, high levels of anxiety and emotional dysregulation are considered within the expected range of reactions and can provide psychological protection in the immediate aftermath.
Sustained, they interfere with basic functions of sleep and eating, and higher order functions of decision-making and performing tasks necessary to sustaining life and maintaining safety.
Prolonged emotional dysregulation can result in problem with decision making, social withdrawal and interference with capacity to fulfil functions of daily living.
Promoting a Sense of Self– and Community Efficacy
Promoting self and community efficacy is designed to achieve a sense of relative control of current circumstances, and to reconnect with pre-emergency coping resources. There is a long tradition of research that identifies social and relational support as mitigating, or, protective factors against the development of traumatic stress reactions.
Promoting Connection
Isolation and displacement are central to traumatic events. Ample evidence that social support and sustained attachments mitigate stress and strengthen mental wellbeing. Promoting connection to one’s immediate personal circle and more widely to communities local, and global, provides conditions for recovery from initial shock, and support in situations of continued stress. Importantly the experts referred to here, caution against negative social support whose defining features include minimising problems, unrealistic expectations regarding recovery, and blaming. They also make the important point that in applying the principle of connectedness, there should be sensitivity to destructive hierarchies of power in personal circles, and in communities.
Hope (normalise emotional reactions, find meaning, and focus on people’s strengths)
Finally, it is well known in the field of trauma studies that traumatic events challenge our sense of meaning and purpose, and can result in existential despair with loss of trust in self, others, and world. As early as the 1989 Janoff Bulman, in her work on sexual assault, argued trauma shatters previous world views, and that the creation of meaning is critical to positive adjustment.
Instilling hope may be addressed to individual agency, but can include reference to spirituality and finding meaning in solidarity and collective responses. Nevertheless, trauma experts caution that where people find themselves stripped of resources, it is necessary to acknowledge their experience, and not allow the promotion of hope to minimize realities or become an unrealistic expectation.
A body of research on the outcomes of PFA is not established. However, a review of the PFA training, and the field guides reveals coherence in incorporation of the five principles outlined above which are empirically supported. A more recent review suggests positive outcomes found by World Health Organization when PFA was used to reduce panic and anxiety during the Ebola crisis in Liberia and Sierra Leone.
Organisations globally using PFA and providing training in this framework, include the World Health Organization, The National Child Traumatic Stress Network, Red Cross Society, Institute of Disaster Mental Health, World Vision, War Trauma Foundation, KIT Royal Tropical Institute, Johns Hopkins University, and Save The Children.
The benefit of the Psychological First Aid approach is that it reduces the risk of developing anxiety, depression, and post-traumatic stress reactions or disorder.
How?
- By normalising reactions to abnormal events
- Mitigating disengagement/dissociation and feelings of loss of meaning, purpose and efficacy
- Participants learn about the coping process
- Promoting coping and foster emotional regulation
- Facilitating social connection
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