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Principles and Practical Procedures for Acute Psychological First Aid Training for
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MENTAL HEALTH ASPECTS OF DISASTER:

PUBLIC HEALTH PREPAREDNESS

AND RESPONSE
Volume 1, Second Edition

Georse r:EffIi,r.., PhD

Gindy L. Parker, MD, MPH

The Johns Hopkins Center fon Public Health Preparedness

Baltimore, Maryland
2CIO5
Ghapten SIX

PRINCIPLES AND PRACTICE OF ACUTE

PSYCHOLOGICAL FIRST AID AFTER DISASTERS

George S. Everly, Jr., PhD

The Johns I{opkins UniversityBloomberg School of Public Health; and
The Johns Hopkins University School of Medicine

RADM Bria,n W. Fhrnn, EdD

Assistant Surgeon GeneraJ. of the United States, Fetired
The Uniformed Services University of Health Sciences

In her now classic treatise on disaster, Beverley H,aphael notes, Eein the
first hours a,fter a disaster, at least 25% of the population may be stunned
and dazed, apatJretic and wandering-sufferin€f from the disaster
s;mdrome-especially if impact has been sudden and totally
devastating&At this point, psycholo€lical first aid aad tria€e&are
necessary&" (F,aphael, I 986, p.257).

It has been noted that, ' In alt disasters, whetJrer they result from tJre
forces of nature or from enemy attack, the people involved are subjected to
stresses of a severity and quallty not generally encountered&It is vital for
all disaster workers to have some fa.miliarity with common patterns of
reaction to unrrsual emotional stress and strain. These workers must also

79
know tJre funda,mental principles of coping most, effectively with disturbed
people. Although [these suggestions have] been stimulated by tJre cument
needs for civil defense a€ainst possible enemyaction& These principles are
essential for those who are to help the victims of floods, fires, tornadoes,
and otJrer natural cata"st'rophes." These words, penned within the
American Psychi,atric Association's monograph Psychologtcal Etrst Aid tn
Commrrnity Disasters, (APA, 1954, p. 5), were written over two
generations a€o and in anoth.er epoch of history. More recently, the
Institute of Medicine (3OO5) has written, *In the past decade, there has
been a €Fowing movement in the world to develop a concept similar to
ph;rsical first aid for copin€lwith stressful and traumatie events in life. This
strateSgr has been hrown by a number of na,mes but is most commonly
referred to as psycholo$ical flrst aid (PfA). Essentially, PFA provides
individuats with skills they can use in responding to psyehologllcal
consequences of [disasters] ln their own lives, a^s well as in tJre lives of
tJreir family, friends, and neigfirbors. As a cornmunity progfa,rr, it can
provide a well-orgarrized communlty task to increase skills, io.owled$e,
and effectiveness in maximizing health and resiliency" (IOM, e0O5, p. 4-7).
Finally, W. Wa.lten Menninger (?OO2), based upon the work of Karen
Horney, has stated that the goal of psychological first aid is to reduce
feetings of isolation, helplessness, and powerlessness. Ttlhile a review of
errrrent literatr.rre on disaster mental health reveals differin$ points of
view on the methods (MMH, eOOe) and even merits of early psycholo$ical
interwention (Wessely & Dea.hl, AOOS), tJrere appears to be virtual
universal endorsement, by relevant autborities, of the value of acute
"psychologrcal first aid" (American Psycbiatric Assoeiation, 1954;
F,aphael, 1986; NIMH,3OO2; Institute of Medicine, ?OO5; WIIO,3OO5; DoD/
VAPTSD, F,itchien et a1., 2AO4; Fri.edman, et 4,1., eOO4). In this chapter, we
shall introduce the notion of psycholo$isal first aid (PFA) a"s one aspect of a
psychological continuum of ca,re, offer a rudimentary definition of PFA,
apd provide tJre reader with a practical framework for its implementation.

A CONTINUUM OF CARE

Early on, the Britisb Psychological Society (1990) suggested that crisis
interwention would likelybe ineffective unless provided as a multl-
componont system. Cument recornmendations for early psychological
intervention argue that such intervention is most effective when applied
within tJre contexb of an inte[pated mu]ti-faceted eontinuum of care
(NIMH, 2OO2; Arendt & Elk1it', 2OOl), Consistent with Theodore Millon's
(Millon, Grossman, Mea4[rer, Millon, & Everly, 1999) concepts of
potentiating pairfn€s (usrng interactin$ combinations of interventlons so
as to achieve an en-b.ancin5l clinical effect), catalsrtic sequenceg
(sequentially combining tactical interventions in their most clinically
useftrl ways), anLd polsrfitetie selection (selecting the tactical interventions

80
as d.eterminedbytbe speciflc needs of each crisis situation), specific crisis
intervention tactics are to be eombined a,nd sequenced in such a rnarlner so
as to yield the most efficient and effective crisis intervention possible. Most
relevarrt to the current discussion, however, tJre earllest point on th.e
continuum of reactive crisis interventions will be acute psychological first
aid.

A DEFINITION OF PSYCHOLOGICAL FIRSTAID

The desire to assist a,n individuat in acute distress can be compelling

indeed. Four issues, however, invariably emerge aS a consequence of tb.at
desire: 1) when to assist, 8) how to assist, 5) whether or not to asslst at all,
and 4) most fund.a,rrental, arrd upon which the three previous issues are
based, is consideration of tbe purynse of intervention. The challenge of
determinin€ wbether to interwene, if interventions have been successful,
and in what contexts, ha,s been confounded by a lack of speeificity
regardjng th.e intended outcome of the interventiOn. In our view, early
interventions maybe dtrected toward a^nyof the followin€f:
. Prevention of a disorder
. Treatment of a disorder
. Frovision ofinformation/education
. Provision of comfort and support (Interwentionbased upon
providing sootJrin$human contact' i,s legitimate and canbe
universall;r applied .)
. Acceleratlon of recovery
. Promotion of ment'al health

Whlle psychological first aid has yet to benefit ftom careful research and
evaluatlon, we are hopeful that it may hold promirse in at least the last four
items above.

According to the Institute of Medlcine (2OO5), "Psychological flrst aid is a

group of skills identilied to limit rlistress and negative health
behaviors&PFA generally includes education about normal psycholo$ical
responses to stressful and traumatic events; skills in active listenin€;
understanding the importance of mai:rtaining physical healtJr and normal
sleep, nutrition, and rest; a,nd understanding when to seek help from
professional caregivers" (IOM, 2OO5, p.7).

The National Institute of Mental Health document' Menta,l Health a,nd Mass
Violence (e0Oe) has enumerated the ftrnctions of psycholo$ical first aid as
includingthe need to&
"Protect survivors from fi,rrther ha,rm,
R educe pb;rsiologieal arousal,
Mobilize support for those who are most distressed,

81
 Keep fa,rnilles to$ether and facilitate reunions with }oved ones,
Provide information a;1d foster communieation and education,
Use effective risk coulmludcation techniques" (p. tE).

B,aphael (19SO) suggests that psycholo$ical first aid consists of the

following:
. Comfort and consotration
. Physical protection
. Provision of physical necessities
. Channeling enersr into constnrctive behaviors
. Reunitln€victims with fuiends, fa,mily
. Provision of behavioral and/or emotional support, especiallyduring
emotionally tardng tasks
. Allowir€ emotiorral ventilation
. Re-establishinS a sense of security
r Utilization of acute social and eommunity support net'works
. Tria€e and referral for those in acute need
. Referral to sub-acute and on-going support networks

Fa,phael (1986) goes on to note that the provision of such acute

psychological support is designed to achieve certaln Soals:

. Encoura4fe the oworkingf throu6S" proeess by reinforcin$ adaptive

coping
. Helpingvictims re-establlsh a sense of mastery (self-efficacy)
. Facilitating access to tJre next' level of oare, if necessary
. Facilitatin€socialreintegfation
Within the contexb of tJris paper, we view a central tenant of psyeholo$ical
flrst aid (PfA) # o& sw)portive aad compwsionate ptesence desigped tP
red.uce rcute psycholo$tcal disfuess."PFA may be used in a wide variety of
circumstances including the stressors of daily life, in fanrlly problems, in
medical emergencies, in canes of loss and tpief, and even in rnass disasters.
Althoug[ there are numerous volumes on the topic of physical first aid'
psychological first aid is a relatively new coneept. While the \,Yorld Health
Orga,:rization (eOOg) and the National Institute of Mental Hea1th (AOOA)
recogpize the importa,nce, a,nd recommend tJre practice, of psychological
first aid, there cqrrently erdst few, practical $ridelines on how it may be
implemented.

THE PRINCIPLES OF PSYCHOUTGICAL FIRSTAID (PFAI

Illtren someone is in acute physical distress, intervention ba"sed upon tJre

principles of physical first aid would apply. One formulation of the basic

82
psychological first aid process follows what may be referred to as the
.3AS.ACC Priaciples:D

Assessment of need for intervention.

StaUitize - Subsequent to s.n initial lntroduction and asisessmentn act so as

to prevent or reduce a worseningl of the cument psycholo$ical or
behavloral status.

Assess triag;e - Once initial stabilgation has been ac}rieved, fi.rther

a;1d"
a,ssessment is indicated with tria6le as a viable option. Assessment of
functionalityis the most essential aspect of this phase.
*5 CS,'Of cOnfldence, concern'
Gommgnicate - Commgnicate tJre a,rrd
compassion.

Gonnect * Connect tJre person in distress to informal and/or formal

support systems, if indicated.

THE PHACTICE OF PSYGHOLIIGICAL FIRSTAID IPFAI

Let us take a closer look at, these rudimentary elements of PFA.

Assessnent - The goa,l of this phase of the interrrention model is to make

an tnitiel assessmeat of, need. If the determination is made tJrat tJrere
exists a need for behavioral or psychological intervention, stabilization is
nexb task to which to attend. In cases where no immediate need for
assistance exists, continued monitoringf may be appropriate for those in
hi€h risk conditions.

Etabilize - Simply stated, the goal of this pbase of the intervention model is
to attempt to "keep thin$s from getting worse." These processes are
intend.ed to diminish the likelihood of an escalatin$ spiral of dlstress while
potentiating a return to psychological homeostasis. This may be initially
achieved by the followin€f:
. Establish "rapport." Ba,pport, is oft,en best founded on the process of
psychological alignment. Psycholo$ical ali€lnment iis borrowed from
the work of clerome Frank (Frank & Frank, 1996) and simply stated
means don't arglre, don't confront, furd something to initially aglee
upon.

83
 o $fs,filization based upon the findin$s of the initia,l
is literally
assessment. The most importa,nt initial determinations to be rnad.e
are of M-I-P:

(l[)Identjfy arry medical tleeds that must be immediatelJr

addressed. Basic ski]] in physical first aid wi]l be useful here.

(I) Determine the level of fimctiona,llty,l.o., is there evidence

of flrnctional imBsimcnt? If functional impalrment is present
to a si€niflcant deglee, appropriat'e support must be soug[t.

(P) Meet anSr basic physicaf needs (food, water, shelter,

reduction of pbsrsical pain, referral for medical care).
. Reduce acute sltuational stressors, if posslble

. Frovide a sense of safety, security

Assess and tria$e - Havin€ stabilized the aaute phase response of the
individual, furtber sssessment of psycholol$cat and behavloral stahrs
seerrrs ind.icated. From the perspective of psycholo$ical first aid, the
Sreatest assessment cballenge becomes differentiatlnSl commonly
e:qperienced "distress" from tbe more severe "d5rsfunction" (clinically
si€FrjJicant, functional impairment). 3.Iligtregs' subsequent to disasters is
to be exlrected in the mqJority of those exposed, with estimates varJrin€f
from 91% in a national survey 5 to 5 days a,fter September lltr', eO01
(Schuster, Stein, et al., 2OOl), and 76.7% in Israeli.rs exposed to terrorism
(Bleich, Gelkopf, & Solomon, 3OO5) to 6g% in samples of a wide variety of
natural and human-made disasters (Norris, et al, 2OO1). Mirdmal if any
intervention beyond. observabion is t5pically required, unless requested, in
the case of "distress." In the case of '{dysfirnctionrtt on the other hand, the
point prevalence is expected to be lower with estimates ranE[n6f from 49%
(Norris, et al, eool), 45% (North, et a1., 1999) and 467o (Norttr, Smith, &
Spitznafel (199?) to perhaps 8O% (Centers for Disease Control' eOO4).
More strrrctured interventlon is catled for in tJre case of "dysfunction," with
serious consideration given to facilitatin$ access to interpersonal support
a,nd continued care. Beyond addressing! medical issues a,nd meeti:ag ba,sic
needs, funotionalit5f becomeg tJre key asgessmelt issue to focus upon.
The ma4lritud.e, or intensity, of the following intervention elements of
psychological first aid wilt depend upon the level of manifest functionality.
In ad.ditionn beyond its obvious face validity, functional impalrment has
been shown to be a predictor of HISD (North, et a1., 3OO2; Norris, et al.,
eOOe) andt'herefore of prospective concern-

84
Assessments performed within the oontext of psyehologfcal first aid mi$rt
be conducted by trained paraprofesslonals, as well as clinicians, who may,
as a result of their assessment' refer someone for & more formal
psychological evaluation by a lieensed mental health elinician.

Gommunice,te - The goal of tJris pbase is to establish a "supportive and

compa*ssionate presence.' fhis may be achieved by communicatinEl what
maybe referred to as the "5 Cs:" confidence, coneern, a,Dd compassion.

Specdftc intenrentions aoutd lnctude the followin$ and ma5r be recalled,

usiDg tJre mnemonic EAnfV (see Appendix A):

tmpathlc llstening Allow people to talk, to tell their story, but

-
don't force conversation and do not pry. [Note: If tJre interventionist
senses that the recipients may be resistant to intervention directly
towards them, it may be of value to utilize the concept of
.(intenrention W pmxy". By ttris we mean that the comments of the
interwentionist' and oth.er group members may be directed toward
assisting those other than tJrose individuals in ttrre cunent group.
Thus, discussions may focus on recoglrizin$ tJre needs of others and
on mettrods for assisting oth.ers who may have difhculty dealin$ with
the a,ftermath of ttrre current sltuation. Such "third party
discusslons may reduce tension or ambivalence about directly
receivin€l assistance. l
Apply stress mana€ement - The application of appropriate stress
mana€ement techniques may include cognitive reframing, problem-
solvin$, suggestions concernlng nutrition, exercise, relaxation, a,nd
interpersonal support.

Reassurance - A confi.dent and compassionate presentation tends

to reduce anxietyin others.

lllormalization - The provision of psychoeducational material to aid

in normalizatlon, self-assessment, anticipatory $ridance, and to
foster resiliency & self-efficacy may be useful.

note: effective interventlon is often based upon active "outreach"

Gonnect - The goal of this phase is to assist the individual in connectin$

with an appropriate psychosocial support system, if desined or otherwise
indicated.

85
 a InformaJ. support systems inelude fa,mily, friends, a,nd co-workers.
a More formalized support s5retems include communitymental health
pro€Fams, employee assistance progFams, student assistance
proEFams, hospitals, a,rrd faith-based resources.
In this final staSe, psycholo$ical first aidmeans esta,blisbingl
effective hu:rran contact's (APA, 1954).

In general., it is important for tJre interventionist to keep in mind the

following points:
. The ma,jority of individuals exposed to a traurnatic event will not
need formal psycholo$ical intervention, beyond bei:ng provided
relevant information.
. The focus shouldbe upon l}:e indivldualmore so tJran the event;
assessment is essential Assessment is an on-going dSma'mie process,
rather than a discrete, static sta$e. Assessment should focus upon
functionality.
. Unless the ma4lritude of impaJrment is such that tJre individua,l
represents athreat to self or others, crisis interwention shouldbe
voluntary.
. fhe interventionist must be carefirl not to interfere with natura.l
recovery or adaptive compensatory mechantisfirs.
. Individuals should not be encoura€led to ta.lk about or rellve the
event, unless they are comfortable doin$ so.
. Psycholo$ical first aid shouldbe developed and conducted in a
culturally competent ilIanner respectin€ such factors as oultura.l
beliefs, how emergencies and traumas are defined, cultural
considerations of how rlistress is expressed and dealt with, what
providers are viewed as credible, and marry other important
considerations. Significarrt and credible gfuidance ls available on
providin€f culturally competent services in crisis set'tin€fs (USDHHS,
2OO5)
. Psychological flrst aid should be viewed a"s one point on a continuum
of disaster menta,l health care which spans the spectrum from pre-
disaster preparation tJrrou$[. psychotJrerapy, and even psychiatric
medication.

SUMMARY

"[A] acute distness following erposlrre to traumatic stressors is best

ma,na€ed following ttre principles of psycholo$ical first a,id. This entails
basic, non-intmsive pra€tnatic care with a focus on listenin$ but not
forcin8 talk; assessin€ needs and ensurin8 tlnt basic needs are met;
encouradltn€f but not forcin€ company from si5pifi.cant others; and

86
protectin€l ftom fi.rrther harm. This t5pe of aid oan be taught quickly to
both volunteers a,rrd professionals" (Sphere Project, ?'OA4, p. e9O. From
both the acute clinical and public health preparedness perspectives, acut'e
psychological first aid represents a potential$r valuable skill set that is
easily applied in tJre wake of mass disasters. Ar€Irably, wherever tJrere is a
need for the application of physieal first aid, there can be a need for the
application of psycholo$ical. first aid. This chapter has offered an
introduetion to psychologlica.l first aid as a public health tool in the wake of
disa.sters and as such maybe of interest and value to alt those interested in
public health issues. Althou€h operationallybasic compared to the practioe
of psychotlrerapy, we believe that competence in PFA still requires
specialized training.

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89

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