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1-PFA-Rapid Proliferation - Disaster Health
1-PFA-Rapid Proliferation - Disaster Health
Keywords: psychological first aid, stress first aid, early intervention, five essential elements, evidence, evaluation
Psychological first aid (PFA) has become the flagship early intervention for disaster survivors, with recent adapta-
tions for disaster responders, in the post-9/11 era. PFA is broadly endorsed by expert consensus and integrated into
guidelines for mental health and psychosocial support in disasters and extreme events. PFA frameworks are prolifer-
ating, with increasing numbers of models developed for delivery by a range of providers for use with an expanding
array of target populations. Despite popularity and promotion, there remains a dearth of evidence for effectiveness
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and recent independent reviews of PFA have highlighted this important gap. This commentary juxtaposes the current
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propagation of PFA against the compelling need to produce evidence for effectiveness and suggests a series of actions
to prioritize and expedite real-time, real-event field evaluation of PFA.
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Rapid Adoption and Proliferation resultant demand from the broader community for early inter-
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of Psychological First Aid vention strategies to ameliorate the negative impacts and to facil-
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“Psychological first aid” was first introduced conceptually in responders returning from stressful missions and subsequently,
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the mid-Twentieth Century;1-3 in the post-9/11 era, psychological debriefing techniques were extended for use with civilian disaster
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first aid has emerged as a mainstay for early psychological inter- survivors. A body of controlled research, however, has raised seri-
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vention with survivors of disasters and extreme events.4-10 Dating ous questions regarding the beneficial effects of this approach in
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from the 2001 National Institute on Mental Health conference terms of long-term recovery. Of more critical concern was a sug-
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on mass violence,11 psychological first aid is now the first, and gestion that, for a minority of recipients, psychological debrief-
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most favored, early intervention approach.4-6,9,10 Psychological ing may actually result in worse adjustment.53,54 PFA emerged in
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first aid has been broadly endorsed and widely promulgated by this context as an intervention that would “first, do no harm”
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disaster mental health experts in reports from a series of con- by retaining the elements of other models most likely to assist
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sensus conferences and in the peer-reviewed disaster behavioral recovery, while avoiding those elements (notably expectations for
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health literature.7,8,11-20 Psychological first aid is also consistently a detailed incident review) that may be iatrogenic.8
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recommended in international treatment guidelines for post- PFA is not a new intervention. Rather, it is better conceptual-
traumatic stress disorder (PTSD) and as an early intervention for ized as documenting and operationalizing good common sense—
disaster survivors.7,12,14-21 those activities that sensible, caring human beings would do for
Since 9/11, numerous psychological first aid frameworks have each other anyway.8 It is underpinned by five “essential elements”
been introduced for use by an ever-growing range of providers generated from the available research literature by a consensus
whose work encompasses an enlarging array of target popula- conference of disaster mental health experts convened in 2004
tions.22-48 Frameworks and models are variously labeled as psycho- and later summarized in a landmark publication by Hobfoll and
logical first aid, community-based psychosocial support, disaster 19 co-authors.55 These five elements are: safety, calming, con-
behavioral health first aid, mental health first aid, and stress first nectedness, self-efficacy, and hope. The various PFA models
aid. For ease and brevity, we will use the term, “psychological adhere to varying degrees to these elements. In simple terms,
first aid,” and the generic abbreviation, “PFA,” throughout this PFA includes the provision of information, comfort, emotional
commentary. A sampling of PFA models is listed in chronological care, and instrumental support to those exposed to an extreme
order, based on year of release, in Table 1. event, with assistance provided in a step-wise fashion tailored to
In recent years, the psychosocial consequences of disaster expo- the person’s needs.8 As a front-line strategy, PFA is not intended
sure have been deftly researched and widely accepted,49-52 with a for delivery by mental health specialists; rather, it is designed to
2006 29
for Public Health Workers Health Preparedness workforce
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B-FAST + SN: Disaster Behavioral Health First Aid Florida Center for Public Health special needs
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2007 31
Specialist Training with Special Needs Populations Preparedness, University of South Florida populations
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disaster survivors
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public health
New York State Office of Mental Health
2007 Psychological First Aid for Healthcare Professionals and healthcare 33
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R-FAST: Disaster Behavioral Health First Florida Center for Public Health disaster first
2008 34
Aid Specialist Training for Responders Preparedness, University of South Florida responders
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2009 Psychosocial Interventions: A Handbook and Red Crescent Societies: humanitarian crisis 37
Reference Centre for Psychosocial Support survivors/refugees/IDPs
International Federation of Red Cross disaster/
Community-Based Psychosocial Support:
2009 and Red Crescent Societies: humanitarian crisis 38
Trainer’s Book: A Training Kit
Reference Centre for Psychosocial Support survivors/refugees/IDPs
International Federation of Red Cross disaster/
Community-Based Psychosocial
2009 and Red Crescent Societies: humanitarian crisis 39
Support: Participant’s Book
Reference Centre for Psychosocial Support survivors/refugees/IDPs
Coping in Today’s World: Psychological
2010 First Aid and Resilience for Families, Friends American Red Cross disaster survivors 40
and Neighbors: Instructor’s Manual
Coping in Today’s World: Psychological
2010 First Aid and Resilience for Families, Friends American Red Cross disaster survivors 41
and Neighbors: Participant’s Manual
Australian Red Cross Australian
2010 Psychological First Aid: An Australian Guide. disaster survivors 42
Psychological Society
Stress First Aid for Firefighters and National Fallen Firefighters Association
firefighters
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be administered by a multiplicity of lay providers, ranging from These complexities may be perceived as potentially so daunting
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professional disaster responders (emergency services personnel, that PFA approaches are routinely launched without prioritiz-
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medical emergency teams) through to teachers, clergy, and PFA- ing, designing, and implementing robust evaluation strategies.
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trained disaster volunteers. While the lack of field evaluations and a credible evidence base
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PFA frameworks are now broadly accessible and available in has been raised at professional meetings, and occasionally in
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a global spectrum of languages. Education on PFA is offered press,6,8,56-59 progress toward addressing this issue continues to
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modalities. Although PFA was initially designed for use with It was, therefore, not surprising that in late 2012, a warning
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civilian disaster survivors, several “stress first aid (‘SFA’)” varia- shot across the bow was delivered in the form of a published sys-
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tions have been recently introduced for use with emergency tematic review of the literature on the effectiveness of PFA.60 The
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response personnel, active duty military combat units, and other review was commissioned by the American Red Cross as part
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high-risk occupational groups.25,29,,32-34,36,43,44,47,48 In short, PFA/ of that organization’s routine process of continuously updating
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SFA in its various forms has rapidly become the universally- the evidence-based literature on the techniques, procedures, and
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accepted early intervention of choice for disaster and trauma interventions that are trained and delivered by Red Cross person-
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affected populations. nel. Most of these reviews focus on medical interventions, but
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PFA was included because the American Red Cross has intro-
What Evidence Currently Exists duced its own version (Fig. 1). This systematic review represents
for PFA Effectiveness? an independent assessment of the effectiveness of PFA; members
of the review committee were experts in disaster response but
The alacrity with which PFA has been adopted as the first line none was a co-author or contributor to any PFA model, nor a
approach in psychosocial recovery following disasters is surpris- participant in the multiple consensus conferences that endorsed
ing. This is, perhaps, an indication of the powerful need to feel PFA. The review process therefore provided a high degree of
knowledgeable and “in control” when dealing with distressed sur- objective scrutiny of PFA using a well-developed and meticulous
vivors—to know what to do and how to best respond to diminish examination of the literature from 1990 through 2010, graded
distress and promote recovery. The simplicity and step-by-step against standardized levels of evidence.
approach of PFA is very appealing in addressing these needs. The results demonstrated the absence of any solid evidence for
Unfortunately, however, PFA’s popularity, promotion, and PFA effectiveness.60 The reviewers were unable to find any ran-
proliferation have not been matched with a commensurate domized trials, nor any non-randomized or even large descriptive
pursuit of evidence demonstrating its effectiveness. Not only is studies. Thus, the best available “evidence” is currently restricted
there a dearth of data regarding the benefits of PFA, but there is to peer-reviewed consensus statements and guidelines. Based on
limited demonstration of widespread commitment to generate the literature review process, the authors recommend support-
such data. There are considerable complexities in the design and ing the use of PFA but note that PFA is “evidence informed but
implementation of PFA evaluation in the post-disaster context. without proof of effectiveness” (p.251).60 Interestingly, even the
and only a few of the more obvious points will be noted here. The
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Figure 1. Cover for Coping in Today’s World: Psychological First Aid and functioning.”23,26 If these are accepted goals, then presumably
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Resilience for Families, Friends and Neighbors, the psychological first aid a repeated measures design with simple assessments of psycho-
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curriculum developed by the American Red Cross.40,41 The American Red logical wellbeing, as well as social and occupational functioning,
Cross commissioned the review of psychological first aid effectiveness. 60
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authors of the review stretch beyond the data in their conclusion PFA that maintain consistency with the existing manuals while
by stating (for people who have experienced a traumatic event) incorporating clearer decision rules that allow ratings of fidelity
“PFA is a vital first step in ensuring basic care, comfort, and sup- to the model and adequacy of implementation of the interven-
port” (p.251).60 tion. Nevertheless, conducting such a longitudinal design in an
The current situation juxtaposes a high level of promotion uncontrolled setting, and maintaining participation over mul-
and advocacy for PFA against a low level of evidence of its effec- tiple waves, pose particular challenges.61
tiveness. Importantly, of course, lack of extant evidence does not Perhaps most importantly, a large majority of disaster sur-
mean that PFA is not effective; rather, that effectiveness has not vivors will recover relatively quickly with the support of family
yet been demonstrated. It is, however, clear that there is an urgent members and friends; PFA is likely to have most impact for a
need to demonstrate the effectiveness—or otherwise—of this small minority who would otherwise not recover.8 Thus, it is
widely used early intervention. important to use designs that do not simply aggregate all the data
into single means, since that is likely to obscure any effects.
Who Should Advocate for It is also important to use measures of outcome that are
Evaluation of PFA Effectiveness? sufficiently sensitive to identify benefits where they occur.
As such, selection of outcome measures needs to consider not
Ideally, disaster mental health experts should continue to raise only domains of symptomatology and wellbeing, such as qual-
a chorus of strong voices for expedited, systematic evaluation of ity of life, alcohol or other substance consumption, depression
PFA effectiveness. It is incumbent upon leaders in the field of and traumatic stress, but also the broader range of knowledge,
Figure 2. Covers, in six languages, for Psychological First Aid: Guide for Field Workers developed by the World Health Organization, War Trauma Foundation,
and World Vision International with special applications for low and middle income countries.45 This version of psychological first aid is being used glob-
ally in humanitarian crises and complex emergencies.
attitudinal, and behavioral outcomes that PFA is intended to intervention can be defined and replicated. One step in the pro-
influence. These broader outcomes include rates of self-referral cess would be to compare the content of the various PFA models.
for mental health treatment, use of coping strategies, amount Actually this process has been utilized by the creators of sev-
and quality of social connections/support, knowledge of disas- eral recently-released PFA curricula who reviewed both the avail-
ter-related psychological reactions, and stigma related attitudi- able literature on PFA and the predecessor models in the field.
nal variables. For example, the World Health Organization (WHO), War
Trauma Foundation (WTF), and World Vision International
What is PFA? Content Analysis and a Link (WVI) joined forces to produce a PFA model that was released
to the “Five Essential Elements” in 2011 for use in humanitarian crises worldwide (Fig. 2).45 In
the process, the WHO commissioned a “Systematic Review of
With the rapid-fire introduction of multiple, and non-equiv- Psychological First Aid”13 and the partner organizations (WTF,
alent, models of PFA/SFA, it would be beneficial to catalog what WVI) created an “Anthology of Resources” on PFA for low and
is being offered. Effective evaluation is not possible unless an middle income countries.62 Furthermore, prior to public release,
The “five essential elements” identified by Hobfoll and col- disaster response professionals, and volunteers. Most of the per-
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leagues (safety, calming, connectedness, self-efficacy, and sons who provide such help are neither trained nor familiar with
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hope)55 might be considered the best “standard” available for PFA. In most instances, practical help is, by its very nature, inten-
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assessing the coverage of various PFA frameworks. Researchers tionally “practical” and “helpful” and only incidentally psycho-
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of PFA models and, as part of the process, they are examining Practical assistance is therefore problematic in terms of evalu-
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the manner and extent to which each of the “five essentials” is ation. Certainly it would be overreach to subsume practical
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addressed.64 Preliminary findings indicate that “calming” and assistance from all sources as part of PFA. However, it should
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“connectedness” are elements that are prominently and consis- be possible to measure the impact of the quantum of practi-
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tently emphasized. Furthermore, these elements appear to be the cal assistance that is provided by PFA providers. This would
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most amenable for evaluation and quantification of psychological be worthwhile because practical assistance is closely related to
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effect. In contrast, “safety” is less developed in most PFA models; problem-solving, a much tested intervention for depression, and
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PFA providers typically arrive on-scene after disaster survivors practical assistance is one of the most important elements across
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have evacuated away from the epicenter of disaster (the “ground multiple models of PFA.
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zero” or “hot zone” scene of high risk and imminent danger) to In summary, components analysis assists the PFA evalua-
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safer environments (with the notable exception of humanitarian tion process by 1) contrasting models in terms of the types and
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crises involving ongoing armed conflict). Likewise, the final two packaging of core actions provided, and 2) identifying those core
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essential elements, “self-efficacy” and “hope,” are more challeng- actions that can be measured in a manner that contributes toward
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ing to measure and to relate to the PFA intervention. Despite the real-time/real-event evaluation of the effectiveness of PFA.
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include these five elements in any PFA evaluation, since they have
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Which Aspects Work Best? Conducting Any evaluation strategy for PFA must recognize and docu-
Components Analysis of PFA Models ment the context in which it is provided: what is the nature of
the potentially traumatizing event, who was affected, and who
Each PFA model organizes its contents around a set of “core is delivering the PFA intervention? Defining the disaster set-
actions” or “core principles” that identify the major components ting and traumatic exposures, the target population, and the
of the intervention. There is notable variability in the enumer- PFA providers is essential for examining the possible differen-
ation and “packaging” of these skills sets. At a minimum, the tial effects of PFA and determining when and where it is most
manner in which the core actions are labeled, organized, and pre- effective.
sented is likely to affect the ease of teaching, acquisition, reten- Exposure to potentially traumatizing events
tion, and especially, in-the-field application of the corresponding It is possible that PFA may be more effective following some
knowledge and skills on the part of PFA providers. disaster and trauma types than others. Different combinations
The components that appear to be “best candidates” for and intensities of PFA components may be applied in events char-
developing data on effectiveness are those that are “psychologi- acterized by acts of human malevolence compared with those
cal” in nature and measurable. Various models label these com- resulting from natural forces; or for events that pose ongoing and
ponents with names such as: comfort, connection, competence, prolonged threat to life (armed conflict situations, natural disas-
confidence, coping, and social support. It is apparent that such ters with widespread devastation) compared with those where
PFA provider
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have been tailored for use with a specific type of provider. The
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has been designed for use by US. Medical Reserve Corps per-
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context. Figure 3. Cover for Psychological First Aid: An Australian Guide, the psy-
chological first aid curriculum developed by the Australian Red Cross.42
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In this article, we have argued for the importance of evaluat- the effectiveness of PFA will be influenced by the environment
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ing the effectiveness of PFA and some of the key questions to be in which the exposure occurs and in which the PFA interven-
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addressed in an evaluation process. We have also acknowledged tion is delivered, the first step of a Phased PFA model should
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the difficulties inherent in designing and implementing a rigor- address organizational policies and procedures dealing with
ous evaluation protocol for PFA in real world settings. We con- psychological trauma. The second pre-event phase involves PFA
clude with five suggestions as to how the challenge of evaluating promotion and staff training, that is, promoting and embed-
PFA may be achieved. ding the policy. Once policies and procedures are in place to
First, recognizing the difficulties of evaluating the use of delineate responsibilities for core PFA actions to various role
PFA with disaster survivors in a disaster context, it has been positions across the organization, this information must be
suggested that an evaluation within the organizational context communicated consistently and regularly to staff at all levels.
of first responders may be a good place to start.8 Here the focus This includes education and training programs to the deliverers
would be the first responders themselves as the affected popula- of PFA in the organizational context (supervisors, managers,
tion. The application of PFA (or more appropriately, the SFA peer supporters and health professionals where relevant) and
models that are now available specifically for responders), in the recipients (being the members themselves), with a view to
an organizational setting with known and predictable ongoing “buddy to buddy” (“mate to mate”) PFA-consistent support.
exposures allows for the development of a phased approach. By Preliminary evidence indicates shifts in knowledge, awareness
undertaking this work, it may be possible to identify ways to and confidence in using PFA interventions by managers and
strengthen the implementation of PFA in less controlled disas- peers following such training.65,66
ter settings. Forbes and colleagues8 outline a phased approach This approach facilitates relatively controlled testing of the
to evaluation, including components to be initiated and mea- elements of PFA within the ranks of first responders, but it must
sured pre-event. The first of these phases is the development be clearly acknowledged that emergency response teams, trained
ness of PFA in real disaster situations with civilian populations tion of persons at high risk for progressing to psychopathology,
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in harm’s way. As previously mentioned, no amount of rigorous inclusion of specialized mental health services referral, and moni-
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testing of PFA elements with responders will replace the need to toring the post-disaster recovery environment.
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warning, there are notable exceptions. For example, we have been The widespread and relatively uncritical acceptance of PFA
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working on community resilience projects with a river commu- as the preferred approach to early intervention following disas-
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nity that routinely engages in an annual “flood fight” when river ter has brought with it concerning questions about its effective-
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levels rise rapidly during the spring thaw; the river has exceeded ness. Although not clearly operationalized, the goals of PFA are
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“flood stage” during 19 of the past 20 years. Other communities broadly recognized as reducing immediate distress and optimiz-
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around the world regularly face the threat of floods, bushfires, ing short- and long-term functioning. Little evidence exists to
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cyclones, and other natural disasters. These communities present demonstrate the effectiveness of PFA in achieving these goals.
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an ideal opportunity to test PFA using a pre-post design. In some Having not been created with field evaluation in mind, research-
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scenarios where multiple communities are affected, there may be ers are now attempting to bootstrap evaluation strategies to PFA
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options to use comparisons in which one area is provided with models that are frankly unwieldy to test for effectiveness. It is
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PFA and the other with an alternative control condition. These now incumbent upon the field to collaboratively design evalu-
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relatively predictable disasters provide opportunities to test PFA ation protocols to test specific aspects and applications of this
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in ecologically valid real world settings in communities that rou- popular and potentially valuable approach. In the final analysis,
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tinely experience disaster threats. we must be able to demonstrate improved trajectories of recovery
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Fourth, evaluation of PFA will be most effective if it is coor- for people affected by disaster and trauma.
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dinated internationally. Ideally we should strive to achieve Note: Just as this commentary was published online, an
agreement on the research questions, measures, and designs to important paper on mental health response to community disas-
achieve comparable methodologies for evaluation of PFA effec- ters was published in a special issue of JAMA.71 Authors Carol
tiveness when conducted for a variety of disaster events around North and Betty Pfefferbaum state, “Evidence-based treatments
the globe. Clearly, this is a significant challenge, but one that are available for patients with active psychiatric disorders, but
is worth striving to achieve. Only by collating and comparing psychosocial interventions such as psychological first aid, psy-
similar studies across different populations will we be in a posi- chological debriefing, crisis counseling, and psychoeducation for
tion to comment definitively about the effectiveness or other- individuals with distress have not been sufficiently evaluated to
wise of PFA. establish their benefit or harm in disaster settings.” This review
Fifth, it is also important to consider the ongoing evolution article reinforces key points made in this commentary.
of the field that will facilitate future enhancements that can be
incorporated into PFA. Our current work with trauma signature Disclosure of Potential Conflicts of Interest
(TSIG) analysis suggests that in the future, early intervention No potential conflicts of interest were disclosed.
of PTSD and related conditions. J Trauma Stress Health Concept of Operations. Available at: http:// Psychological First Aid: Field Operations Guide,
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